Name / Date of Birth:
Current address:
Phone number: / Mobile:
Ok to leave a message? Yes/No / Ok to leave a message? Yes/No
Email address:
How can South Somerset Mind contact you?
Home phone Mobile phone call Mobile text
Email Post
When we receive your referral form, we will email or text you, within 3 working days to let you know that we have received your referral. If you would prefer for South Somerset Mind to phone you to let you know we have received your referral, please tick this box –
Details of referrer
Are you referring yourself (self-referral)?

Yes* No
*If you are self-referring to South Somerset Mind please continue on page 2.
Referrer’s name / Role
Organisation
Address
Email address* / Telephone
*If you provide a valid email address South Somerset Mind will contact you to confirm receipt of this form

Referral form

Do you have any Mental Health Problems?
Please describe any past or current problems you would like support with.
If you have a diagnosis, what is it?

Do you agree with this diagnosis? Yes No
How long have you had your Mental Health problem?
Less than 6 months 6 months -1 year 1-2 years
unsure other (please state)
Physical Health problems
Please describe any physical health problems, so that we can offer you the best support for your needs. (Including medication i.e., Asthma inhaler, EpiPen, Angina spray)
Please provide us with you GP contact details
Doctor’s name
Surgery Address
Telephone
Would you like support in the following areas?
Anxiety
Depression
Improving my confidence
Improving my social skills
Gaining new skills
Other ______
Please provide details of any other agencies/ individuals that are supporting you. e.g social worker, housing officer, care worker, other voluntary organisations
Name / Role
Organisation
Address
Email address / Telephone
Name / Role
Organisation
Address
Email address / Telephone
If you have more organisations supporting you, please continue on the back of this sheet.
In case of an emergency please contact
Name Relationship
Telephone
Is there anything you need me to do if a medical emergency occurs?
No Yes please tell us what we can do for you:
What Service would you like to access?
Mental Health Wellbeing Groups
Langport Crewkerne Yeovil
Glastonbury Shepton Mallet Frome

Vanessa Gardening Project
Yeovil Community Day
Youth Matters (Frome)
Risk issues
If there are risk issues for you, we can usually still offer you a service. By telling us about these issues, you help us ensure our services are safe for yourself and others.
Do you have any history of risk to yourself or others? For example self-harm, attempted suicide, self-neglect, violence to others, sexual offence, arson, violence to property, arson?
No Yes
If yes please give details, and whether or not this is a current risk.

All personal information will be added to our secure database online. The information you have provided to us will be kept strictly confidential. The only time confidential information will be disclosed is if you are at risk of harm to yourself or to another person and disclosure may be made to a line manager, your GP or other health professional.

Declaration to be signed by referrer (or person requiring service if self-referral)
I give permission for South Somerset Mind to request and/or provide information from/to my GP or any other professional and organisational body if I am at risk of harming myself, or someone else.
I understand that my referral and personal information may be shared with staff within the organisation of South Somerset Mind, and that this will be treated with the strictest of confidence by all employees, unless a risk has been disclosed.
I/We have read, understood, agreed with and completed all the sections on the form
Name (please print)…………………………………………………………………………
Signature…………………………………………………….. Date………………………

How did you hear about South Somerset Mind?

……………………………………………………………………………………………………………

Please note we will add you to our mailing list so that you receive information on South Somerset Minds activities, events and opportunities please tick if you do not want to receive any information

We use anonymous case studies to help us to report to funders and other agencies the experiences that people have at South Somerset Mind, if you do not wish us to use you in a case study please tick here

Personal data

Please complete as many of the following questions as possible but if you do not wish to answer any question please skip to the next one, all information will be treated as confidential and will only be used for monitoring purposes.

Ethnic origin (please circle) / White / Asian or Asian British / Black or Black British / Polish or other eastern european / Chinese / White Irish / Other ethnic group
Do you consider yourself to have a disability or long term health condition? /
Yes /
No
please circle all that apply / Mental Health condition / Physical Health condition / Learning disability/
difficulty / Develop
-mental
disability / Behavioural Disability i.e. Asperger’s / Deafness/
Partial loss of hearing / Blindness/
Partial loss of sight
Please could you indicate your current employment status
Employed full time / Employed part time / Unemployed
Self employed / Employed but off work due to ill health / Retired (due to age)
Retired (due to ill health) / Student / Housewife/husband
Volunteering / Long term Illness/
Not fit to work / Carer
Other please specify:

What is your religion/belief:

Christian / Buddhist / Hindu / Jewish
Muslim / Sikh / No religion / Other…………..
Do you consider the area where you live to be:
Urban Semi Urban Rural
What is your accommodation status?
Own home Social housing Private Tenant Homeless Supported Housing
What is your gender: Male Female Transgender
Sexual Orientation:
Heterosexual Bisexual Lesbian Gay Other Prefer not to say


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