Mind Matters NHS Professionals Referral Form

Mind Matters is a Surrey based Talking Therapies service who only accept referrals from GPs and Professionals where the person is registered with a GP surgery based in the SURREY HEARTLANDS and SURREY HEATH Integrated Care Board areas

I confirm that my patient is aware their personal information will be held securely on the Mind Matters system. My patient consents to consents to anonymised data to be sent to the Department of Health as standard. We are unable to process referrals for patients who do not give consent.

I confirm the above

Yes

My patient consents to this referral and their information shared with Mind Matters

Yes

Your patient is important to us and we will need to be able to contact them easily, please complete ALL fields including permissions to contact.

Name of Referrer

Job Role

GP Surgery / Organisation

Contact Number

Contact Email

Address

Registered GP Name

GP Practice Name

GP Contact Number

GP Contact Email

Title

First Name

Last Name

NHS Number

Date of Birth

Address Line 1

Address Line 2

Town/City

Postcode

Home phone number

Permission to leave a voicemail

Yes

Mobile phone number

Permission to leave a voicemail

Yes

Permission to send SMS

Yes

Email address

Only complete if permission to contact via Email

Reason for Referral and Expectations for Treatment

Risk Assessment Notes

Has the patient had recent contact with secondary Mental Health Services

Yes

Don't know

If yes, please give details

Is an interpreter required?

Yes

If Yes: please state language

Is your patient pregnant or has child under 24months?

Yes

Is your patient a veteran?

Yes

Does the patient have a Learning Disability?

Yes

If yes, please specify

Please complete the captcha

Mind Matters NHS Professionals Referral Form

Referrer contact information if different to the GP

Registered GP Details (If not the Referrer)

Essential Patient Contact Information

Further Details