Health Professional Online Referral Form

This online referral form is only to be used by health professionals, and specifically for referrals to the Herefordshire Healthy Minds therapy team – it is not for referrals to Primary Mental Health Nurses.

All fields need to be completed where indicated *.

Title*

First Name*

Last/Family Name*

Date of Birth*

NHS Number*

Address Line 1*

Address Line 2

Town/City*

County*

Postcode*

Mobile Number

G.P. Surgery Name*

G.P. Name*

G.P. Surgery Address*

G.P. Contact Number*

Has the person being referred given consent for the referral and agreed to us contacting them on the details provided?*

Yes

If consent is not given then we are unable to process the referral without indication of explicit consent from the person being referred.

Referrer Name*

Referrer Team & Address*

Contact Number*

Referrer Email*

Referral Reason (Identified problem)*

Is there any Risk to Self/others?*

Current Medication (including dose and duration)*

Smoking History:*

Smoker

Ex Smoker

Current non smoker but past smoking history

Never smoked tobacco

Language*

Able to communicate in English?*

Yes

Interpreter required?*

Yes

Seen by Mental Health services before? If yes, please give details*

Any further information relevant to referral?

Please complete the captcha

Health Professional Online Referral Form

Patient Details

GP Details

Referral Source

Referral Details

Patient’s Requirements/Needs

Other Details