Washington Mind's Listening Ear Service Referral

Washington Mind's Listening Ear Service Referral

Please complete the form below with as much accurate information as possible in order for us to process the referral and offer appropriate support. If this form is not fully completed, we will be unable to offer a triage appointment and we will inform you of this. If you, or the person you are making the referral on behalf of, is a significant risk to self/actively suicidal with plan, please VISIT A&E IMMEDIATELY or contact NHS 111 Mental Health Team which can be reached by calling: 111 and dialling option: 2.
About the person making this referral
Who is making this referral?
Name of person making this referral

First NameLast Name
Organisation of person making this referral
Email address of person making this referral
example@example.com
Phone Number for the person making this referral
Please enter a valid phone number.Format: (000) 000-0000.
Date of Referral

DayMonthYear
Date
About the person who would like to access Listening Ear Support

If you are completing this referral on behalf if someone else, please complete these questions with their details.
Name

First NameLast Name
Preferred Name
Date of Birth

DayMonthYear
Date
Gender
Phone Number
Please enter a valid phone number.Format: 0000 000 0000.
Is it okay if we send a text?
Is it okay if we leave a voicemail?
Email
example@example.com
Preferred contact method
Address

Address Line 1

Address Line 2

CityState / Province

Post Code
Name of GP Practice
Are you a veteran?
Are you an asylum seeker?
Are you a refugee?
Are you currently pregnant, or have been within the last 12 months?
Do you have a criminal record
Do you have any physical or learning disabilities?
If yes, please specify
Do you have any long-term physical or mental health conditions?
If yes, please specify
About the referral

If you are completing this referral on behalf if someone else, please complete these questions with their information.
Just briefly, how would you describe the reason you would like to access support?
Have you had any past involvement with mental health services?
If yes, please specify service names and approcimate dates of involvement.
Apart from your GP, are there any other professionals incolved with your care at the moment? E.g. Health Visitor, Social Worker, CPN, etc?
If yes, please specify service names and approcimate dates of involvement.
Who is currently living in your household?
From the way you have been feeling recently, do you feel like you are at risk to yourself or anyone else?
Should be Empty:

Washington Mind's Listening Ear Service Referral

About the person making this referral

About the person who would like to access Listening Ear Support

About the referral