Referral Form

Please complete the following information which will help guide us to support you. We will contact you within 3 working days, if you would like to speak to someone sooner or are unable to complete the form please click the call back button or call us on 020 8637 6279, email us at grenfell.wellbeingservice@nhs.net or come and see at us our base at St. Charles Centre for Health & Wellbeing to make a referral.

Are you filling in this form for yourself?*

Yes

No

What would you like help with?

Title*

First Name*

Last Name*

Date of Birth*

If you are completing this for a child, please provide name of parent/carer:

Address Line 1*

Address Line 2

Town/City

County

Postcode*

Telephone Number*

Can we leave a voicemail?*

Yes

No

Can we send you a text message?*

Yes

No

E-mail

Telephone number of parent/carer (if applicable):

Can we leave a voicemail?

Yes

No

Can we send a text message?

Yes

No

How would you prefer us to contact you?

Would you be happy for us to contact you with information about services we offer? (e.g. therapy groups and events)*

Yes

No

Would you like the service to provide an interpreter?*

Yes

No

If so, which language?

We would be grateful if you could share some more information with us (optional):

Gender:*

Ethnicity:

If your Ethnicity is not listed above please describe here:

Nationality:

GP Practice

GP Name (if known)

Do you have any access needs that we need to be aware of? e.g. mobility issues or any other health needs

Do you have any preferences (e.g. days/times for contact, face to face/ remote, or preference for who you would like to speak to, e.g. therapist from a particular gender, faith or ethnicity?)

Where did you hear about us?

If you selected 'Community Event' or 'Other', please give details:

We will do the best we can to try to accommodate your preferences but where we are unable to, we will discuss this with you.

Please complete the captcha

Self Referral Form

Basic Information

Further Information