About You

First Name
Last Name
Preferred Name (if different)
Date of Birth
Gender Identity
Phone Number
Email Address
NHS Number (if known)
GP Surgery
Emergency Contact Name & Phone

Address

Address line 1
Address line 2
Postcode
County
Town / City

Your Support Need

Have you ever, or are you currently, experiencing mental health difficulties?
Learning needs or support with reading/writing
Adjustments to help you take part
Any risks we should know about

Your Mental Health and Wellbeing

Medical conditions we should know about
If yes, please share as much or as little as you wish (optional)

In the last 3 months, what face to face appointments have you had with health professionals?

GP appointments
Number of contacts and reason for attending
Mental Health Nurse appointments
Number of contacts and reason for attending
Social Worker appointments
Number of contacts and reason for attending
Community Mental Health Team contacts
Number of contacts and reason for attending
Number of A&E visits due to mental health
Have you had any hospital admissions for mental health

About Your Daily Life

Accommodation Type
Employment/Education Status
Do you consider yourself to have a disability?
Main Disability
Do you use any equipment or technology to help day to day?
Are you a Carer?
Do you have a Carer?

Equality and Monitoring

Ethnic Group
Sexual Orientation

Getting to Know You

How did you hear about us?
Do you have any unspent criminal convictions? Having a conviction will not necessarily stop you from volunteering, but will need to be taken into consideration when assessing your suitability. Please provide details

Declaration

Confidentiality at Trust Links & Agreement to Share Personal Information

If you would like a copy of the data entered on this referral form for your records, please enter your email address here