Referral Form

Please complete all questions below - Your referral may not be processed until all the necessary information has been received.

If you need help completing this form, please email info@mindinbexley.org.uk giving your name and telephone number - a staff member will then call you within a few days to help complete the form.

Title:*

First Name:*

Surname:*

Date of Birth:*

Gender:*

Sexuality:*

Relationship Status:*

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Landline Number:

Can we leave a voicemail on this number?:

Yes

No

Mobile Number:

Can we leave a voicemail on this number?:

Yes

No

Can we contact you by SMS?:

Yes

No

Email:*

Please write your email address again:*

GP Name and Practice:*

NHS Number:

Are you currently pregnant?:*

Yes

No

Is your partner currently pregnant?:*

Yes

No

Are you a parent of a baby under 12 months?:*

Yes

No

First language:*

Religion/Faith:*

Interpreter Required?:*

Yes

No

If yes, what language?:

Next of kin name:*

Next of kin relationship to you:*

Next of kin phone number:*

Special needs or adjustments:* (for example, you are a wheelchair user)

What is your ethnicity?:*

Do you have a registered disability?:*

Yes

No

If Yes, please specify:

If Other, please specify:

Any other health details which are important for us to know?:*

Have you ever received treatment (CBT/Counselling/other) for your mental health?:*

Yes

No

If yes, please provide details to include when, where and whether this was helpful:

Have you ever received a mental health diagnosis?:*

Yes

No

If yes, please provide details to include where and when you were diagnosed and what the diagnosis is:

Are you currently on a waiting list or receiving therapy from another mental health provider such as Oxleas?:*

Yes

No

If yes, please provide details:

Services required?:*

Talking Therapies

Recovery College and Workshops

Employment Support for individuals with mental health issues

Support if you are caring for a friend/relative with mental ill health

Digital Hub - support to improve your digital skills using a phone, tablet or computer

Crisis Cafe

Please provide a reason for your referral, and what you would like support with?:*

Please let us know your availability for a 45 minute telephone assessment within the next 14 days:

We use your phone number to call and text you about appointment information. We use your email address to contact you about your referral and also to seek feedback while you are engaging with our service or shortly afterwards. Therapists may also use your email address to contact you about appointments and send you resources. Please make sure you have written it accurately on the first page of this form.

People have told us that emails from us sometimes go into their spam folders. Please check these folders in your email account to ensure that you haven’t missed correspondence from us.

Please select to confirm that we are able to contact you by:*

If we are unable to reach you, can we leave a message?:*

Yes

No

Information you share with us is confidential between you, our service and your GP. The only time we will break this confidentiality is if we are concerned that there is a serious risk of harm to you or someone else. We store information on our IT system. This is confidential, and cannot be accessed by anyone outside of our service. We do share anonymous information with NHS England and other statutory bodies that monitor our performance. This information may include details on the number of people we see, what type of treatment they receive, or if they recovered. This does not include your name, address, contact details etc.

Please confirm you understand and agree to the above:*

Yes

If we think your needs are better met by another service, we would normally share your information in order to make a referral. Are you happy with this?:*

Yes

No

Where did you hear about us?:*

Thank you for completing the above information, you will be contacted in due course.

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Self Referral Form

Your Personal Details

FURTHER INFORMATION

SERVICE INFORMATION