Referral Form | Mind in Somerset

Client Details

Full Name *

Date of birth *

Address *

Town *

Email

County *

Postcode *

Phone number *

Mobile number

How would you like to be contacted?

Phone
Email
Text

Is it OK to leave a message?

Yes
No

Referral type

Self-referral
Referral by another (Organisation, family etc)

Referrer name

Referrer phone number

Referrer email

In case of emergency please contact

Relationship

Telephone

Is there anything you need me to do for you if a medical emergency occurs?

GP details

Name of GP

Surgery address

Telephone

Email

Do you have any other relevant agency in statutory services? Care coordinator, therapist, floating support worker etc.

Yes
No

Job title

Name of professional

Address of professional

Telephone of professional

Email of professional

Reason for referral being made

Presenting issues

Please select the service(s) you are interested in

Hopes for the future and key outcome required

Diversity Monitoring Data (optional)

Ethnic origin

Employment status

Do you consider yourself to have a disability or long term health condition?

Yes
No

Please tick all that apply

What is your religion/belief?

Do you consider where you live to be

Urban
Semi-urban
Rural

What is your accommodation status?

With which gender do you identify?

Sexual orientation

GDPR/Data Protection Privacy Notice

Mind in Somerset collects, processes and stores the personal data in this form (and collected while we provide support) for three reasons only under the legal basis of provision of medical services. First, to contact you about your mental health and to arrange appointments. Secondly, to safeguard you and others and to provide case referrals to mental health partners in line with our legal obligations. Disclosure of your data may only be made to your GP, NHS bodies, your next of kin, statutory services, Compass Disability Services, or to other mental health professionals. Finally, we use anonymised data to monitor diversity and to provide statistics to those who fund and regulate us. Mind in Somerset may also share anonymised data with other local Mind associations or Mind. You have the right to request a copy of the data we hold on you by writing to us or emailing us. Complaints can be made in writing or by email by contacting us in the usual ways displayed on our web site. All data will be held for ten years from the date a referral is made and then deleted.

All personal information will be added to our secure online database. The information you have provided to us will be kept strictly confidential.

Declaration by referrer (or person requiring service if self-referral)

Single Checkbox Field *

By ticking this box I confirm that I have read and understand the Privacy Notice above. I also agree that Mind in Somerset can contact me for the purposes outlined in the Privacy Notice above. If I am not the data subject, I agree that I have consent from the data subject to agree to the above Privacy Notice on their behalf. For children under 13 consent is required from the parent/guardian

Checkboxes

First Choice
Second Choice
Third Choice

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Client Details

GP details

Diversity Monitoring Data (optional)

GDPR/Data Protection Privacy Notice

Declaration by referrer (or person requiring service if self-referral)