Professionals Referral Form

Professionals Referral Form

Referrals via Voluntary Sector, Social Care, Higher Education and Health Professionals etc.
Date of Referral:

DayMonthYear
2 digit day, 2 digit month, 4 digit yearDate
Please Note: Wellbeing Exeter only works with adults in Exeter aged 18+.

Wellbeing Exeter works with individuals who have the capacity and understanding to make informed decisions on their own behalf or with the support of others. If you are uncertain about whether the individual meets this criteria, please contact us directly to discuss before submitting this referral form.
Consent
Does the individual / appointed representative give consent for their details to be shared with Wellbeing Exeter?
Person's Details

Please note that we can only take referrals in the Exeter area for adults aged 18+.
Name:

First NameLast Name
Preferred Name (if different from above):

First NameLast Name
NHS Number (if known):
Date of Birth:

DayMonthYear
Gender:
Preferred Pronouns:
Address (by providing your address, we may contact you by letter if required):

Address Line 1

Address Line 2

CityCounty

Postcode
To understand your needs better and help us provide the right support, we would prefer to complete a quick telephone welcome call. Please provide us with a working mobile or landline number to enable us to do so.

Area CodePhone Number
Email (please provide if available):
Alternative Contact Preferences (tick all that apply):
Carer Information

Please fill in this section if applicable - if not, then move on to the next section.
Does Wellbeing Exeter need to contact a carer on the person's behalf?
Carer's Name:

First NameLast Name
Carer's Email or Phone Number:
Referrer's Details
Referrer's Name:

First NameLast Name
Referrer's Job Role:
Referrer's Place of Work:
Referrer's Phone Number:

Area CodePhone Number
Referrer's Email:
Reason For Referral
Please give brief details of your reasons for referring this person:
Other Referrals Made
Please give brief details of other relevant referrals you have made for the person or any agencies that are already involved with supporting the person (i.e. DPT, CAMHS, social care etc):
Risk Awareness
Are there any risks we should be aware of, such as:

Other
Please give details below:
Disclaimer: Wellbeing Exeter reserves the right to limit, suspend or refuse services to anyone based on our professional opinion, and at our discretion at any time, and without giving details or reasons.
www.wellbeingexeter.org.uk
Should be Empty:

Professionals Referral Form

Consent

Person's Details

Carer Information

Referrer's Details

Reason For Referral

Other Referrals Made

Risk Awareness