121 - Self Referral Form with remote and F2F

Self Referral Form- Use this form if you would like to request a service for yourself. (Please complete all boxes)
Which service you would like to access?

CounsellingMentoringGroup WorkNot Sure
Where did you hear about our service?
Other
Where did you hear about our service?

WellbeingMindGPChattertonThurlow HouseOther (Please Specify)
Name
Date of Birth

DayMonthYear
Date
Address
Post Code
Gender

MaleFemaleOther
Please provide all contact details and state your preferred method of contact.
Landline Number
Mobile Number
Email Address
example@example.com
How do you want to be contacted?

LandlineMobileEmail
How do you want to be contacted?

leave a message with someone answering my phoneleave a message on my answering machinesend 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
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?
How would you like your service?
How would you like your service?

RemoteVia ZoomTelephoneFace to Face
Please outline any specific needs which we may have to be aware of:
Language?
Cultural?
Access?
Disability?
Other?
Signed

Clear
Date

DayMonthYear
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.pd
Should be Empty:

Please provide all contact details and state your preferred method of contact.

Your GP's Details

About You