• Referral Form

    One Stop Mental Health Support, Redbridge
  • Are you referring yourself or someone else?*
  • Are you a professional?*
  • Consent 1 Actual
  • Consent 2 Actual
  • In order to complete a referral, ALL of the following criteria must be met*
  • Declaration Actual

  • Your details

  • As the person making the referral, please enter your own details below.


  •
  • Format: 00000000000.
  • Are you a professional with the North East London NHS Foundation Trust (NEFLT)?*
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  • Your details

  • Referee's details

  • As the person making the referral, please enter the details of the person being referred below.

  • Date of birth*
     / /
    2 digit day, 2 digit month, 4 digit year

  • Format: 00000000000.
  • Interpreter Needed?*
  • Disability*
  • Registered with GP*
  • Format: 00000000000.
  • Reason for referral*

  • Risk assessment

  • What are the primary mental health diagnoses?*
  • Is there a history of self-harm or suicidal ideation?*
  • Are there any current suicidal thoughts?*
  • Has there been an admission to a mental health hospital in the past 5 years?*
  • Is there any risk to others?*
  • Are there any safeguarding concerns?*

  • Current support and interventions

  • Are any other support services currently involved?*
  • Is any medication currently being taken for mental health conditions?*
  • What type of support is required?*

  • Additional information

  • Should be Empty: