Easy Read Referral Form
Do you need information in easy read?
Yes
No
If the answer is no please fill in our self referral form at gateway.mayden.co.uk/referral-v2/dec9c353-60f4-47d6-a4fa-2a4b16bc8a76
This form is a way for you to get free support and advice from your local talking therapies service.
The service is for people who are feeling sad or worried. We can help you to cope with how you are feeling.
We do not offer emergency support. If you need help right now please contact your:
• GP
• A & E department at Queen Elizabeth Hospital
• Call the Oxleas 24- hour Mental Health Crisis Line on 0800 330 8530
• Call 111
• Samaritans 116 123
Completing this form means you are happy for us to contact you.
You may need to ask someone you know well to help you complete the form.
If you need any help filling in this form, phone us on 0203 260 1100
What would you like to be called?
Mr
Mrs
Miss
What is your first name?*
What is your surname?*
What is your date of birth?*
Are you…*
Male
Female
Prefer not to say
What is your address? (where you live)*
Which town/city do you live in?
What is your postcode? (for example SE18)*
What is your mobile number?*
What is your home number?
Which is the best number to reach you on?
Mobile number
Home number
Can we leave a voice message?*
Yes
No
Do you have a disability?
Yes
No
I don't know
If you have a disability please tell us which one:
Learning disability
Problems hearing e.g. hearing aid
Problems seeing
Moving around e.g. use a wheelchair, use a walking stick
Memory and understanding
Do you have any physical health problems?
Yes
No
Not sure
How would you like us to communicate with you?
Easy read
Large letters
Braille
Information by email
Signing e.g. Makaton
Advocate (someone speaking on behalf of you)
Interpreter (English not first language)
British Sign Language (BSL)
What is the name of your GP surgery?
What would you like help with?*
Feeling down
Feeling stressed
Feeling worried
Panic attacks
Worrying about your health
Feeling worried around people
Obsessions/OCD
Trauma
Something else - Please write it here:
We will contact you to arrange a time to ask you some more questions.
Please tell us who you would like us to contact?*
Just me
A family member
A friend
Someone else
If you would like us to contact someone else this means your information will be shared with this person.
Are you happy for this information to be shared with this person?
Yes
No
Name of other contact:
What is their relationship to you? (for example friend, family member, carer)
Their phone number:
Please complete the captcha
Submit
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