Referral Form

We are best able to help you if your main issue is low mood, stress or anxiety difficulties. If you are experiencing more chronic and enduring mental health or substance misuse issues you could benefit from seeing your doctor (GP) before completing a self-referral form to our services to help you choose the most appropriate service for your needs.

If you are in need of immediate help because of a mental health crisis and feel unable to keep either yourself or someone else safe, please call 999.

You can contact the NHS Helpline on 111.

If you would prefer to use our interactive referral system, please visit our website on www.wellbeingnands.co.uk By using this option we can gather more information from you and identify the right person for you to talk to. There is plenty of opportunity for you to tell us in your own words how you are feeling and what you are hoping to get help with.

Please complete the following fields. Even if you are already registered with us, it will help us to process your request more efficiently.

Title

First Name

Last Name

Date of Birth

Gender

Preferred Pronouns:

If other, please specify:

Address Line 1

Address Line 2

Town/City

County

Postcode

Preferred Phone Number

Preferred Phone Type

Is it ok to leave a voice message on your preferred number?

Yes

No

Do you consent to receiving text messages?

Yes

No

Other Number

Email

Please enter your email address again

By giving us this information we are assuming that you consent to being contacted in this way.

Do you struggle with any form of communication? ( for example; answering the phone, responding to texts/emails, opening post etc)

Yes

No

If yes – Please tell us what you struggle with and how we can best communicate with

If you would be happy for us to contact you through another person, please give us their details (including any contact details)

By providing this information it doesn’t act as consent to share information about your care with this person, it means in case of emergency they would be the person we would contact.

Would you like to provide emergency contact details?:

Yes

No

First Name:

Last Name:

Relationship:

Contact Number:

GP Surgery

Nationality

Ethnicity

Do you require an interpreter?

Yes

No

Do you need a sign language interpreter?

Preferred language?

Sexuality

Do you have any long term medical conditions?

If yes, please specify:

If other or multiple long term conditions, please specify:

Do you have a disability?

Are you a NHS member of staff?

Yes

No

Are you an ex-British Armed Forces member?

Are you pregnant or do you have a child under two years old?

Yes

No

Can you tell us a little bit about what you would like some help with

Have you experienced, or witnessed, or been subject to hearing about a significant traumatic event? This could be something which was life threatening, or resulted in serious injury, and/or involved sexual violence?

Yes

No

If yes, are you seeking help because you are experiencing memories of the event that come into your mind against your will?

Yes

No

Where did you hear about us?:

If Other, please specify:

We are committed to improving the care we provide, and to do this, we want to hear from those who use our services. If you might want to help improve The Norfolk and Waveney Wellbeing Service, please express your consent to be contacted in the future by ticking the box below.

Please tick here:

Yes

No

Your referral may be passed to one of our partner organisations for treatment these organisations are Xyla Digital Therapies and Dr Julian.

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To learn more about how we manage your information please see our privacy policy at https://www.wellbeingnands.co.uk/norfolk/privacy-policy/

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Self Referral Form

Personal Details

Emergency Contact Information

Doctor (GP) Details

Further Information