Referral Form

If you would like advice and guidance only and would prefer to not give your details, please call the colleague support line on 0300 124 5595. Open Monday-Sunday, 09:00-17:00

Please select:*

If you were advised to refer to the Colleague Support Service, please select by whom:

Please be aware that NHS England requires us to collate and share demographic data for research and service improvement purposes. We require your consent for data sharing.

Please select:*

Yes

No

If you have any concerns or would like more information about this, please contact Colleaguesupport@somersetft.nhs.uk

Do you agree for this data to be collated?:*

Yes

No

Please complete to enable us to process your referral.

Title:*

First Name:*

Last Name:*

Are you known by any other name? (this is to help us find medical notes, only if required):

Gender:*

Date of Birth:*

Address Line 1:*

Town/City:

County:

Postcode:*

Do you have a previous address within the last 3 Years?:*

No

Yes

If Yes, please enter it here:

If you happen to know your NHS number, please enter it here:

GP Name:

GP Practice Name:*

Preferred Phone Type:*

Preferred Phone Number:*

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

Yes

No

Do you consent to receiving SMS?:*

Yes

No

Preferred Email address:*

Can we contact you by email (specifically to send you a questionnaire about your symptoms prior to your first appointment)?:*

Yes

No

Name:*

Address (including postcode):*

Contact number:*

What is their relationship to you?:*

What is the reason for your referral?:*

If Other, please specify:

Relationship Status:*

Ethnicity:*

Sexual Orientation: Which of the following best describes how you think of yourself?*

I work:*

Contracted hours:*

Job title:*

Where do you work from?:*

Where is your work base?:* (i.e Musgrove Park Hospital, County hall)

Do you work for Somerset Foundation Trust (SFT)?:*

Yes

No

If you work for the NHS (SFT), which directorate do you work under?:

If you work for the NHS please select your job role from the following:

Please complete the captcha

Referral form

Consent Details

Personal Details

Contact Details

Next of kin details

Referral Information

Further Information