Referral Form

Thank you for choosing to self-refer to the Staff Wellbeing Hub. This form takes one to two minutes to complete. We need this information to offer a safe and responsive service so please complete the form as fully as you can.

We know how important confidentiality is to many people accessing the Hub. Your information will be kept confidential within our separate secure recording system. Only the Staff Wellbeing Hub team have access to this. We would always gain your permission before sharing your confidential information with anyone else. As with any service, there may be very rare occasions when we are required to override confidentiality. Examples of such rare situations are safeguarding issues, or significant immediate risk that cannot be otherwise managed.

If you are worried about completing this form, please contact us by telephone or email, and we will be happy arrange a time to confidentially discuss your concerns.

This form is received by the hub between 9am - 5pm on Monday to Friday, except bank holidays.

We are not able to provide urgent crisis care. If you are struggling with feelings of hopelessness and in need of immediate help there are a number of services that can help straight-away. SHOUT provide a confidential dedicated 24/7 text service for health and social care staff - Text NHSPH to 85258. You can also call the Samaritans for free on 116 123 (UK and the Republic of Ireland). You can also contact your local mental health crisis service and details of your local service can be found here https://www.nhs.uk/service-search/mental-health/find-an-urgent-mental-health-helpline

Title:*

First Name:*

Last Name:*

Gender:*

Male

Female

Prefer to Self Describe

Prefer Not to Say

Date of Birth:*

Preferred Phone Number:*

Phone Type:*

Is it ok to leave a voice message?:*

Yes

No

Permission to Send SMS?:*

Yes

No

Please specify your address details below:

Home

Work

Address Line 1:*

Postcode:*

Email:*

Permission to send email?:*

Yes

No

How would you like us to get in touch with you?:*

Please could you suggest three times when you are free to have a conversation with us?*

Do you have any communication or access needs we need to be aware of? (please state):

Are you currently off work?:

Yes

No

Are you considering taking time off work?:

Yes

No

Where do you currently work?:*

If other, please state:

Which staff group do you work in?:*

If other, please state:

Did you work in a critical care / intensive care unit during the pandemic?:*

Yes

No

I don’t know (I am completing the form on behalf of someone)

What type of service do you work in?:*

If other, please state:

What is your ethnicity?*

What is your sexuality?*

In your own words, please let us know the reason you are contacting the Hub:*

Please only complete the following two questions if you are completing the form on behalf of someone else, and only if they are happy for you to do so.

If you are completing this form on behalf of someone else, please choose your role or service from the list:

If you are completing this form on behalf of someone, please provide your name, service name, email, telephone number, and any additional information you wish to share.

Please complete the captcha

Self Referral Form