Self Referral Form
Thank you for referring into Mind Matters Surrey.
IMPORTANT: Mind Matters is a Surrey based Talking Therapies Service and accepts referrals from Surrey Residents who are registered with a GP in Surrey and Surrey Heath.
In taking your details, we recognise the importance of personal privacy and make sure all information about you is held securely in accordance with the General Data Protection Regulation (GDPR)
We use data anonymously for monitoring purposes. However, no one will be able to link any information back to you.
Everything you tell us is kept confidential, however if you disclose information concerning current or potential harm or risk to yourself or another, we may need to tell another party including your GP, the Police or Ambulance Service.
If you disclose current or historical abuse or information related to a crime, we are legally obliged to inform the Police and/or other safeguarding agencies.
To ensure quality of care we are required to share information with your GP about your referral and treatment which we may do both verbally and in writing.
Please confirm that you agree with these terms and conditions
Yes
Personal Details
Title
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
Mx
First Name
Last Name
NHS Number
Everyone registered with the NHS in England and Wales has their own unique number. Your NHS number is normally shown in a '3-3-4' format e.g. 943 476 5919 (this is an example number only) and it can be found on any letter or document you have received from the NHS, such as prescriptions, test results, and appointment letters.
Date of Birth
Gender
Male
Female
Transgender
Gender Non-Binary
Other
Not known
Not specified
Address Line 1
Address Line 2
City
County
Postcode
Home phone number
Can we leave messages?
Yes
No
Mobile number
Can we leave messages?
Yes
No
Can we contact you by SMS?
Yes
No
Email address
Can we contact you by email?
Yes
No
By confirming that Mind Matters Surrey can correspond with you via email, you are agreeing that Mind Matters Surrey can send you via email, where necessary, confidential personal information. Any personal information sent by us, will not be encrypted or sent in a locked file format. Therefore, Mind Matters Surrey cannot be held responsible for the security of your personal information transferred to you by email.
National Identity
Please Select A Value...
British
English
Irish
Scottish
Welsh
Other
Ethnicity
Please Select A Value...
White - British
White - Irish
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Any other Asian background
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Any other Black background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Gypsy/Traveller
Other Ethnic Groups - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
Religion/Belief Affiliations
Please Select A Value...
No religious group or secular
Atheist / Agnostic
Church of England
Other protestant
Orthodox Christian
Roman Catholic
Other Christian
Muslim
Shi'ite Muslim
Sunni Muslim
Sikh
Jewish
Orthodox Jewish
Buddhist
Hindu
Jain
Parsi / Zoroastrian
Rastafarian
Any other religion
Main Spoken Language
Please Select A Value...
Akan (Ashanti)
Albanian
Amharic
Arabic
Bengali & Sylheti
Brawa & Somali
British Signing Language
Cantonese
Cantonese and Vietnamese
Creole
Dutch
English
Ethiopian
Farsi (Persian)
Finnish
Flemish
French
French creole
Gaelic
German
Greek
Gujarati
Hakka
Hausa
Hebrew
Hindi
Igbo (Ibo)
Italian
Japanese
Korean
Kurdish
Lingala
Luganda
Makaton (sign language)
Malayalam
Mandarin
Norwegian
Pashto (Pushtoo)
Patois
Polish
Portuguese
Punjabi
Russian
Serbian/Croatian
Sinhala
Somali
Spanish
Swahili
Swedish
Sylheti
Tagalog (Filipino)
Tamil
Thai
Tigrinya
Turkish
Urdu
Vietnamese
Welsh
Yoruba
Other
Do you require an interpreter?
Yes
No
If Yes: please state language
Sexuality
Please Select A Value...
Heterosexual
Lesbian or gay
Bisexual
Other
Not known
Not stated
Relationship Status
Please Select A Value...
Single
Married
Divorced
Widowed
Separated
Co-Habiting
Long term
Civil Partnership
Not Disclosed
GP Details
GP Practice Name
GP Name
Further information
Do you have any long term medical / health conditions?
Please Select A Value...
Yes
No
If Yes, please select
Arthritis
Asthma
Cancer
Chronic Fatigue
Chronic Kidney Disease
Musculoskeletal disorder (MSK)
Chronic Obstructive Pulmonary Disease (COPD)
Chronic Pain (including Fibromyalgia)
Chronic Pancreatis
Coronary Heart Disease
Crohn’s Disease
Dementia
Diabetes
Eating Disorder
Epilepsy
Hypertension / high blood pressure
Irritable Bowel Syndrome
Medically Unexplained Symptoms
Osteoporosis
Parkinson’s Disease
Severe Mental Health Problems
Stroke and Transient Ischaemic Attacks
Thyroid problems
Other
None
Decline to say
Do not know / not sure
Do you have a disability?
Please Select A Value...
No Perceived Disability
Behaviour and Emotional
Hearing
Manual Dexterity
Learning Disability
Asperger’s syndrome
Mobility
Perception of Physical Danger
Personal Care
Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits, etc)
Sight
Speech
Other
Prefer not to say
Do you have a confirmed diagnosis of Autistic Spectrum Disorder (ASD)?
Yes
No
Have you ever served in the armed forces or are you a dependent on someone who has served?
Please Select A Value...
Yes - ex services
No
Dependant of a ex-serving member
Not stated (Person asked but declined to provide a response)
Unknown (Person asked and does not know or isn't sure)
Are you pregnant or have a child under two years?
Yes
No
Are you currently seeing a mental health professional?
Yes
No
If Yes, please specify:
Psychiatrist
Community Psychiatric Nurse
Community Mental Health Team
Substance Misuse team
Private therapist or counsellor
Psychological therapy team – Mind Matters
Psychological therapy team – other
Other/prefer not to say
Do you have history of violence towards others or have been involved in Criminal Justice System or Police?
Yes
No
Over the last 2 weeks, how often have you been bothered by the following problems?
Feeling nervous, anxious or on edge:
Please Select A Value...
Not at all
Several days
More than half the days
Nearly every day
Not being able to stop or control worrying:
Please Select A Value...
Not at all
Several days
More than half the days
Nearly every day
Little interest or pleasure in doing things:
Please Select A Value...
Not at all
Several days
More than half the days
Nearly every day
Feeling down, depressed, or hopeless:
Please Select A Value...
Not at all
Several days
More than half the days
Nearly every day
We will contact you within 3 working days of our receiving this referral. With an assessment being offered within 10 working days.
Mind Matters Surrey is not a crisis service, if you feel concerned about your mental health whilst waiting for us to contact you and feel at risk to yourself or others you should see your GP as soon as possible.
In addition, the following resources may be helpful;
NHS Direct - Tel; 111 (anytime)
The Samaritans - 116 123 (24 Hours support)
Surrey and Borders Crisis Line - Tel; 0800 915 4644 (24 hours support)
Please note for confidentiality reasons our telephone number is withheld. A message will only be left if we have specific client consent.
In submitting this referral you are confirming that you understand that you can access the services stated above whilst waiting to be assessed by our service.
Where did you hear about the Mind Matters Service?
Please Select A Value...
GP
Friend/ Family
Website
Facebook
Twitter
Publication/ Leaflet
Other Medical
School/ College
Internet Search
CSPA
Single Point of Access SPA
CMHRS
CMHT
Rosebery School
RSCH Staff
Staff Resilience/Wellbeing Hub
Other - please specify
If other, please specify
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