Self Referral Form

Thank you for referring into Mind Matters Surrey.
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.

Personal Details

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.
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.

GP Details

Further information

Over the last 2 weeks, how often have you been bothered by the following problems?
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.