Referral Form

Please answer each question as fully as possible.

By submitting this form you are consenting to us sharing information with your GP.

Title:*

First Name:*

Last Name:*

Date of Birth:*

You must be over 16 to access this service, if under 16 please call Forward thinking Birmingham on 0300 300 0099

Email:

(Please only provide if you give permission for us to email you including information about your care)

Do you consent to completing online forms to help with your care?:*

Yes

No

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Accommodation Type:

Settled Accommodation Indicator:

Gender:*

Female

Male

Non-binary

Not known

Is gender the same as that assigned at birth?:

Home Number:

Mobile Number:

Please provide us with at least one contact number.

NHS Number:

GP Name:

GP Surgery:*

Can we send you text message reminders for appointments?:*

Yes

No

Is it ok to leave a message on your voicemail and say it is Birmingham Healthy Minds?:*

Yes

No

Would you like to give us permission to talk to anyone else about your care?:*

Yes

No

If yes, what is the name of the person, their relationship to you and their contact number?:

Are you a Refugee/Asylum Seeker?:*

What is your religion?:

Is English your main language?:

Yes

No

What is your preferred language?:

Do you need an interpreter?:

Yes

No

Do you have a disability?:*

Yes

No

Not stated

If Yes, please specify:

If you have a Long Term Health Condition please let us know what it is?:

If Other, please specify:

Are you a member or ex-member of the British Armed Forces?:*

How would you describe your sexual orientation?:*

What is your ethnicity?:*

What is your marital status?:*

Please can you tell us who you live with? (Include any children’s names and their date of birth):*

Are you or your partner expecting a baby or do you have a child under 24 months old?:*

If yes to the above:

What is the main problem or difficulty you would like some help with and how long has this affected you?:*

How does this problem affect you? (How does this problem affect the way you think and feel? What symptoms are you experiencing? How does it affect what you do?):*

How would you like things to be different?:*

Have you currently been prescribed any medication for your mental health?:*

Yes

No

Don't know

If so, what have you been prescribed and since when?:

Do you find yourself using alcohol or taking recreational drugs to help you cope with your problems?:*

Yes

No

If Yes, please tell us more:

Have you had previous contact with mental health services, or therapy/counselling?:*

Yes

No

If Yes, please give the details of these and dates if possible:

Is there anything else we should know before we make any appointments for you?:

How did you hear about the service?:

Please note, Birmingham Healthy Minds is not a crisis service. If you are currently experiencing distressing thoughts and feel you may be at risk of harming yourself or someone else, please contact one of the following: your GP or out-of-hours service / NHS Direct on 111 / Birmingham and Solihull Urgent Mental Health Helpline on 0121 262 3555 / The Samaritans on 116 123.

In an emergency dial 999 or visit A&E.

Thank you very much for completing these questions. We will contact you once we have reviewed this form.

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Birmingham Healthy Minds

Personal Information

Reasons for referral

What happens next?