Service user name
Address
Postcode
Phone
Email / Has this person been referred before
Mobile:
Date of Birth / Gender / : NHS Number
Referrer or Key worker / (please circle) Professional referral. Carer referral. Other.
Name & position
Service
Address & postcode
Telephone
Email
Have you talked to the Making space or Leeds Mind office to discuss this referral? Mind
Making Space
How long do you anticipate remaining involved with this person?
Only on receipt of all completed documentation including a separate Risk assessment will this referral be processed and the referral agent be contacted to arrange an assessment.
GP’s Details. Name Telephone
Address
What other services are being used? (e.g. Community Psychiatric Nurse [CPN], Community Support Team, Day Centre, Home Support, Housing Support, Social Worker, psychiatrist)
What is the Mental Health Diagnosis or Concern(s) ......
Volunteers meet and spend time out in the community with service users of the scheme.
Are there concerns/ difficulties using Buses, cars or taxis?
Are there concerns about going out on dark evenings?
Are there concerns around mobility?
Can you let us know what interest areas may be relevant and/ or enjoyed?
For example
walking around the town centre shopping areas, walking in the country, Cinema, Visiting a Café, Restaurants, Taking walks, Pub Lunch, Ten Pin Bowling, Swimming, Arts & Culture, Education, Employment, Faith & Spirituality, Social Groups, Sport & Exercise, Volunteering.

Expectations of using this service

How does mental ill health affect day-to-day life?

What support is needed?

Are there any physical health concerns?

Is there anything else you feel that we should know?

Risk Assessment Information

1. Are there any issues related to drugs or alcohol? Yes No

2. Has there been any threatening, aggressive or violent towards others? Yes No

3. Are there any issues around self harm? Yes No

4. Has there been any exclusions from any services? Yes No

In addition to the above information we require a “FACE” risk assessment or similar for all referrals

Please check the information given and sign here to indicate you agree with the information.

Person being referred:

I agree to this information being shared among relevant professional agencies

Signature...... Date......

Referrer:

This form is being submitted with the full knowledge and consent of the person referred

Signature...... Date......

Return to: Leeds Befriending and Peer Support Service.

Making Space. The Office, Waterhouse Court, Joseph Street, Hunslet, LEEDS. LS10 2AF

Tel 0113 2761421 email

Demographic Equality Monitoring Form.

We want to make sure that all our services are delivered fairly. We are therefore ask the following questions about the referred, so that we can make sure that our services include everyone’s needs.

Please tick your answer

Ethnic Background / Black - African / Mixed - White / Asian
Black - Caribbean / Mixed - White / Black African
White - English / Black - Other / Mixed - White / Black Caribbean
White - Welsh / Asian - Bangladeshi / Mixed - Other
White - Scottish / Asian - Chinese / Other - Arab
White - Northern Irish / Asian - Indian / Other - Gypsy/ Traveller
White - British / Asian - Kashmiri / Other - Other
White - Irish / Asian - Pakistani / Prefer not to say
White - Other / Asian - Other / Did not ask
Disability / Religion/ Belief / Marital Status
None / Buddhist / Married
Physical / Christian / Single
Sensory / Hindu / Civil Partnership
Mental Health / Jewish / Co-habiting
Learning / Muslim / Other
Long Standing / Sikh / Prefer not to say
Prefer not to say / Other / Did not ask
Did not ask / No religion
No belief
Prefer not to say
Did not ask
Sexual Orientation / Residency
Heterosexual / British Citizens
Lesbian/Gay woman / EU Nationals
Gay man / Foreign Students
Bisexual / Asylum seekers
Prefer not to say / Refugees
Did not ask / Destitute
Heterosexual / Others
Do not know
Prefer not to say
Did not ask