GROUP REFERRAL FORM
Which Service would you like to access?
Community Group
Workshop
Not Sure
Your Details
Name
Date of Birth
-
Day
-
Month
Year
Date
Address:
Post Code
Gender
Male
Female
Other
How we Contact You?
Please provide all contact details and state your preferred method of contact.
Landline Number
Mobile Number
Email Address
example@example.com
Please tick a, b, or c if you DO NOT give permission
a) Leave a message with someone answering my phone
b) leave a message on my answering machine
c) send reminders via text message to your mobile
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
Have you had counselling in the last 12 months? If yes, please give details
Have you had any thoughts of suicide in the last three months?
Yes
No
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?
Yes
No
If yes, please give details:
What are you hoping to get out of Group/Workshop?
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
-
Day
-
Month
Year
Date
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