Referral Form

About this referral

If you need to speak to someone urgently, please consider the following contacts (https://www.beusupport.co.uk/urgent-help/) including the mental health crisis team (0808 196 3779)

The Be U Notts Service is here to provide early intervention for mild to moderate mental health difficulties.

Things can seem overwhelming. For example, you may:

• feel sad or hopeless

• have problems with your family, friends or at school

• hurt yourself or have thoughts about hurting yourself

• feel anxious and scared

• have trouble sleeping

• feel angry or are struggling to control your behaviour or temper

• find it hard to concentrate

• find it hard building or maintaining relationships with friends

• have lots of worries

• do not like yourself or have low self-confidence

• have other things on your mind that you find difficult

Please fill in your details below and someone from the Be U Notts Service will get in touch to discuss how we can help you. We are currently experiencing huge demand for our services and are working hard to meet your needs as quickly as possible.

Or you can phone us: 0115 708 0008

So we can give you accurate and appropriate advice, we sometimes need to share the details you have provided with others such as your GP, social worker or any other services, relevant to the support we provide to you.

By accepting this, you are giving consent for your personal information to be shared with those relevant professionals. The sharing of your details is carried out in compliance with the Data Protection Act 2018. For more information on Data Protection visit https://www.gov.uk/data-protection

Customer declaration:

• I give consent for the Be U Notts Service to share my details with relevant professionals /organisations to help the Be U Notts Service to give me accurate and appropriate support.

• Once given, I may withdraw consent at any time, by writing to the Be U Notts Service Manager and asking for my referral to be cancelled. This will mean I will be discharged from the service, notification sent to my referrer if relevant and my referral will be closed on our secure patient database.

• I agree that information provided will be stored on a secure Be U Notts database for a minimum of 2 years and to be used anonymously for monitoring purposes.

I have read the above information and agree:*

Yes

No

Title:*

First Name:*

Last Name:*

What is your preferred/chosen name?

Date of Birth:*

Gender at birth:*

Gender you identify with?:*

Male

Female

Non-Binary

Preferred Pronouns:*

Do you have a diagnosed disability?*

Yes

No

Do you have a diagnosis of autism or any other neuro-developmental difficulties (Examples: ADHD)?*

Yes

No

If yes, please provide as much information as possible:

Address Line 1:*

Address Line 2:

Town/City:*

Postcode:*

How can we best contact you:

Mobile Telephone:*

Can we leave a message:*

Yes

No

Can we contact you via SMS:*

Yes

No

Email:*

Do your parents/carers know that you are contacting us:*

Yes

No

Do you give us permission to contact them if needed:*

Yes

No

Please be aware in safeguarding situations if you are under 16 we will be required to contact parents/ carers.

What is their name?*

What is their phone number?*

Please describe what you currently struggle with and how this impacts you on a daily basis? (consider impact on school, social life, family, relationships, sleep, eating etc)*

How long have you felt this way? Did anything happen to lead to this change?*

Have you ever or do you currently self-harm? Please provide details:*

Have you ever or do you have current thoughts or plans to end your life?*

Are you currently seeing or waiting to see any other professionals / services?*

Are you receiving / have you received support for your feelings from any other services? Please detail:*

Please provide any historic information regarding the above if applicable (last 12 months):*

Do you use drugs/alcohol?*

Yes

No

If Yes, what substance(s) and how regularly?

Name of School/ College/ Education Provider:*

How did you hear about the Be U Notts Service?:*

If 'Other', please provide details:

Please complete the captcha

Young People

About this referral

Consent

Who is making this referral?

Reason for Referral