121 - Mentoring Self-Referral Form 2

Your Details:

Name

Date*

Gender

MaleFemaleOther

Address

Postcode

How we Contact you?

Landline Number

Mobile Number

Email

Confirmation Email

Please tick if you give permission

leave a message with someone answering my phoneleave a message on my mobile phonesend reminders via text message to your mobilesend an email

Your GP's Details:

GP Name:

Practice Address:

Practice Tel No:

Prescribed Medication:

Are you currently receiving support from another service? (e.g. Psychological/psychiatric services)

Please provide information about any past support from mental health services?

About You

What are your current difficulties?

Have you had any thoughts of suicide in the last three months?

YesNo

If yes, please give details: (Please note that the One to One Project is not a crisis service. In the event of current thoughts of suicide, please contact Samaritans on 116 123 or the Crisis Team on 0300 790 0371 if you are already a Trust user)

Do you have any difficulties with alcohol and/or non-prescribed drugs?

YesNo

If yes, please give details:

What would you like to achieve with the support of the One to One Project?

Where did you hear about the service?

Please outline any specific needs which we may have to be aware of:

Language?

Cultural?

Access?

Disability?

Other?

Signature

Date

Today's Date

To view the One to One Project’s privacy notice and to find out how we use the information you have supplied, please visit http://www.onetooneproject.com/wp-content/uploads/2018/06/Privacy-Statement.pdf

The One to One Project will never share or disclose information contained in this form to third parties or any person outside of the organisation. The person named on the form has the capability to forward their information and as such, the One to One Project takes no responsibility for client information shared by clients to people or organisations outside of the One to One Project.

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