• Birmingham & Solihull Mental Health and Wellbeing Hubs – Referral Form

    Please note that 1-2-1 support is ONLY available between 9-5pm Monday to Friday
  • Our service is eligible for individuals 18+, registered with a GP in Birmingham & Solihull who meet one of the following (Please tick as appropriate):*

  • Contact Details

  • Date of Birth*
     - -

  • Referrer’s or Community Mental Health Team Details

  • GP Details

  • Demographic Information & Equal Opportunities

  • Gender*
  • Ethnicity*
  • Sexuality*
  • Religion*

  • Safety and Wellbeing Information

    We ask for details about areas that may affect your safety or wellbeing, so we can provide the right support plan for your mental health. We may contact you or other professionals involved in your care (e.g. GP, support worker or mental health team) for more information, but please provide as much detail as you can.
  • SELF-HARM: Is this a current concern?*
  • SELF-HARM: Historical or current?
  • SUICIDAL: Is this a current concern?*
  • SUICIDAL: Historical or current?
  • SELF-NEGLECT: Is this a current concern?*
  • SELF-NEGLECT: Historical or current?
  • WORRIES ABOUT PERSONAL SAFETY: Is this a current concern?*
  • WORRIES ABOUT PERSONAL SAFETY: Historical or current?
  • VIOLENT OR AGGRESSIVE BEHAVIOUR TOWARDS OTHERS: Is this a current concern?*
  • VIOLENT OR AGGRESSIVE BEHAVIOUR TOWARDS OTHERS: Historical or current?
  • ADDICTIONS: Is this a current concern?*
  • ADDICTIONS: Historical or current?
  • CRIMINAL HISTORY: Is this a current concern?*
  • CRIMINAL HISTORY: Historical or current?
  • SEXUAL OFFENCES: Is this a current concern?*
  • SEXUAL OFFENCES: Historical or current?

  • Mental Health Conditions

  • Mental Health Conditions: (Please tick all that apply)*

  • Mental Health Needs

  • Additional Neurodivergent Needs

  • Additional neurodivergent needs*

  • Emergency Contact

  • Location Preference

  • Our hubs are across Birmingham & Solihull, and you can access all hubs once registered. The Recovery Navigator you are assigned will be based in one of these hubs. From the list below, please tick which area you would prefer:

  • Please state preference for location?*

  • Please note that your assigned hub may differ from preference depending on hub capacity or individual needs

  • Communication Preference:

  • Before attending the hub, your assigned Recovery Navigator will get in touch with you to talk about the service and find out a bit more about you. From the list below, please select how you would prefer to be contacted:*

  • Service User Agreement

  • The Mental Health & Wellbeing hub’s are safe, supportive spaces where we work together to improve mental health and wellbeing. We ask everyone who uses the hub to treat others with kindness and to help take care of the environment we share. By accessing the hub, you agree to uphold these values. If behaviour does not align with these expectations or compromises the safety or wellbeing of others, you may be asked to leave and may not be able to continue accessing the hub.

  • Privacy, Consent & Information Sharing

  • We may collect further information from third parties, statutory and voluntary agencies who you have worked with you. We use your information to: Help meet your needs in the safest and most effective way and work effectively with other organisations involved in your care. We will always ask for your consent before sharing in this way.  Sharing of information between Birmingham Mind & Creative Support may take place to ensure our service can meet your needs. We may share anonymised data with the people that fund our services. All your information is held securely and is only accessible by those who have permission to see it. You have the right to: be informed of your rights and how your data is used, request access to a copy of your information, have your information corrected or updated and remove your consent at any time.

  • The person being referred has consented to this referral*
  • The person being referred has consented to sharing their information*

  • Referrer Confirmation

  • Date
     - -
  • Should be Empty: