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Greenwich Peer Support

Professionals Referrals form

Welcome to SEL mind and to the Greenwich Peer Support service - If you would like to refer your client into Greenwich Peer Support, please complete this form. Please note that we will only accept referrals where the client has consented to being referred to the service.

Please note that all fields with a red * are compulsory, and you must complete them to be able to save and submit this form.

To access Peer Support clients must be a Greenwich borough resident or have a GP registered in Greenwich. The service is 18+ only.

Peer Support clients will have access to groups run by coordinators and volunteers with lived experience of mental health conditions. The service does not provide one to one support.

We store and process personal data in line with the 1998 Data Protection Act and the 2018 General Data Protection Regulations. For a full copy of our Privacy Policy please see https://www.selmnid.org.uk/privacy/ or you can ask for a paper copy by calling 020 8853 2395

Risk Assessment

Please share relevant information about support needs including any risk information (risk to self, risk to others, risk from others, risk within group work)

Identity

Forename of client

Surname of client

Date of birth of client

Address

Address line 1 of client

Address line 2 of client

Town

Client's Postcode

Borough client lives in

Bromley Lewisham Greenwich Other

Contact

Client's mobile number

Client's email address

Client's Emergency Contact Details (name, relation, phone, email, address)

Service communication preferences?

Permission to leave messages

GP Details

GP Surgery name

GP's address

GP's telephone No:

Consent - Demographics

Section to record consent to hold demographic information

Does the client give consent for us to process and store their demographics information?

Date of Consent or non-consent (Special category data)

Source of Consent (Special category data)

Additional Information

Please share anything else you think would be helpful for our team to know