Referral Form

This information is kept on our electronic database strictly under the terms of data protection law and will not be shared with anyone outside the department. We collect this data purely for reporting purposes to ensure we are working as effectively as possible to enable all communities in Shropshire County to access our service.

* indicates required field

NHS Number (if known):

Title:*

First Name:*

Preferred Name:

Last Name:*

Date of Birth:*

Gender:*

Male

Female

Not known

Not specified

Is your gender identity the same as the gender you were given at birth?:*

Yes

No

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Landline Telephone Number (inc. area code):

Ok to leave voicemails?:

Yes

No

Mobile Number:*

Ok to leave voicemails?

Yes

No

Ok to text?:

Yes

No

Email address:

We are available for administration purposes Monday to Friday 9am till 5pm. Please could you let us know if there are any times within this in when you would be unable to take our calls?*

Place of Work:*

Job Role:*

Telephone Number:

GP Name:

GP Surgery:*

Consent to inform GP?:*

Yes

No

Ethnicity:*

Sexuality:*

Religion/Belief:*

Preferred Language:*

Can you read and write in this language?:*

Yes

No

Preferred format for written information: (e.g. English, Braille, Easy-read, font size 14, Polish, Urdu, etc.)

Do you have a disability?:*

Yes

No

If yes, please state:

Are you in contact with any other mental health services?:*

Yes

No

If yes, please state service name:

Please provide a brief outline of why you are contacting the Hub:

Any other relevant information you would like us to know: (referral details, veteran status, pregnant/have a partner who is pregnant, parents of a child 12 months old or under, etc.)

Where did you hear about our service?:*

Please complete the captcha

Shropshire and Telford & Wrekin Staff Wellbeing Hub Self-Referral Registration Form

Personal Details

Place of Work

GP Details

Further Details