Bikur Cholim Referral Form
Thank you for choosing to refer to Bikur Cholim. Our talking therapy service is open to adults over 18 from the Charedi Orthodox Jewish community, registered with a City and Hackney GP and who has a mild to moderate mental health issue (can be undiagnosed). Please fill in the details below. The information you provide is confidential and is gathered and stored in accordance with the UK GDPR and the Data Protection.
Patient Details
Name
First Name
Last Name
Address
Street Address
Street Address Line 2
City
Postcode
Phone number
Patient consent for voicemail message
Yes
No
Date of Birth
-
Day
-
Month
Year
NHS Number
Gender
Ethnicity
Main GP Surgery
Interpreter needed?
Yes
No
Is patient on any waiting list for psychological treatment?
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Referrer Details
Date of Referral
-
Day
-
Month
Year
Name of organisation
Name of Referrer
First Name
Last Name
Address
Street Address
Street Address Line 2
City
Postcode
Phone number
E-mail
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If the client is under the care of a primary/ secondary Mental Health Service:
Name of Service:
Contact/Key Worker
Contact Number:
Contact email address:
Reasons for Referral for Psychological Treatment
Risk Factors
History of self-harm
Current self-harm
Problems with drugs
Problems with alchol
Suicidal ideation
Suicidal intent/plan
Previous suicide attempt
Previous harm to others
Domestic violence
Safeguarding adults
Safeguarding children
Please give details of previous or current Interventions/ Therapy/ Referrals to other services:
Submit Form
Should be Empty: