Referral Form

Personal Details

Title:*

First Name:*

Last/Family Name:*

Date of Birth:*

Gender:*

Address Line 1:*

Address Line 2:

Town/City:

County:

Postcode:*

Mobile Number:*

Permission to leave voicemail?*

Yes

No

Permission to send texts?*

Yes

No

Email address:*

Permission to send email?*

Yes

No

Do you need an interpreter?*

Yes

No

Preferred Language:*

Ethnicity:*

Sexuality:*

GP Practice:*

Are you NHS or social care staff?*

NHS

Social care

Organisation:*

Role:*

We gather further information on role and organisation to better inform our services and the care we are providing. We will not share any details with your workplace unless it is agreed after assessment that an occupational health referral is needed.

What is the main problem?* (brief description)

How did you hear about Keeping Well?*

Permission to contact your OH department (if necessary)? Please note only relevant information will be shared (e.g. when work is significantly impacting health or health is significantly impacting work). This will be discussed with you before any contact is made*

Yes

No

Do you consent to your anonymised data being used for research purposes?*

Yes

No

Do you consent to being contacted for research purposes?*

Yes

No

The next step is we will call you for a telephone assessment to find out more about your difficulties and discuss next the support options available.

Assessments are available Monday - Friday, between 8am and 4.15pm.

Please specify your availability for a telephone assessment e.g. Tuesday 10-11, Friday 9-3.30pm, or 'Monday' or 'anytime'.

Please offer as may times as you can:*

(If you would prefer to speak to us before arranging this, please call us on 020 3228 3563 or email slm-tr.keepingwell.sel@nhs.net)

Permission to inform GP of referral and outcome of referral:*

Yes

No

Please note we always share information about risk with GPs. Even if you select no here, any risk concerns will be shared with your GP.

Please complete the captcha

Self Referral Form

Personal Details

Further Details