Rochdale & District Mind Referral Form
Identity
Prefer to be known as
Gender
Please Select
Male
Female
Non-binary
Prefer not to say
Other
Forename
Surname
Date Of Birth
Day
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Month
January
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Year
2035
2034
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1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
Language
Please Select
English
Urdu
Punjabi
Bengali
Polish
Portuguese
Kurdish
Other
Do you need an interpreter?
Please Select
Yes
No
Address 1
Address 2
Town
County
Post Code
Are we okay to send a letter?
Please Select
Yes
No
Landline Telephone
Are we okay to leave a message on the landline?
Please Select
Yes
No
Mobile
Are we okay to leave a message?
Please Select
Yes
No
Are we okay to text?
Please Select
Yes
No
Email
Are we okay to Email?
Please Select
Yes
No
Have you accessed Rochdale and District Mind's services before?
Please Select
Yes
No
Not Sure
Demographic and Monitoring
How would you describe your ethnic background?
Please Select
Anglo Indian
Arab
Asian - Bangladeshi
Asian - Chinese
Asian - Indian
Asian - Other
Asian - Pakistani
Black - African
Black - British
Black - Caribbean
Black - Other
British Pakistan
Do not wish to state
Gypsy or Irish Traveller
Iranian
Mixed - Other
Mixed - White & Asian
Mixed - White & Black African
Mixed - White & Black Caribbean
Nigerian
Other
Polish
Portuguese
Romanian Gypsy
Slovak
South East Asian
Spanish
Thai
Unknown
White - British
White - German
White - Irish
White - Other
White Eastern Europe
Do you consider yourself to have an impairment, health condition or learning difference that has a substantial or long term impact on your ability to carry out day to day activities? (Please tick all that apply)
A long standing health condition or physical impairment (such as epilepsy or using a wheelchair)
A mental health problem (such as depression or schizophrenia)
A social/communication/learning difference (such as speech and language impairment or Asperger's syndrome)
A sensory impairment (such as a visual or hearing impairment)
Any other
None of the above
Prefer not to say
How would you describe your sexual orientation?
Please Select
Bi
Gay/Lesbian
Heterosexual/Straight
Prefer to self-describe
Prefer not to say
Have you ever identified as trans?
Please Select
Yes
No
Prefer not to say
Gender Same At Birth
Please Select
Yes - the person's gender identity is the same as their gender assigned at birth
No - the person's gender identity is not the same as their gender assigned at birth
Not Known (not asked)
Not Stated (person asked but declined to provide a response)
How would you describe your religious beliefs?
Please Select
None
Christian
Buddhist
Hindu
Muslim
Jewish
Sikh
Do not wish to state
Other
How would you describe your relationship status?
Please Select
Married
Co-habiting
Single
Civil partnership
Do not wish to state
Other
How would you describe your residency status?
Please Select
British Citizen
EU National
Refugee
Asylum Seeker
Do not wish to state
Other
Are you a veteran? (ex-service person)
Please Select
Yes
No
Do not wish to state
Are you a Carer?
Please Select
Yes
No
Do not wish to state
Do you have a disability?
Please Select
Yes - physical issues
Yes - mental health issues
None
Do not wish to state
Not completed
Other
Details of Referrer
Are you completing this form for yourself?
Please Select
Yes
No
Referrer's name:
Role
Please Select
Advocate
Alcohol / Drug Worker
CPN
Counsellor / Therapist
Employment Advisor
GP
Occupational Health Advisor
Probation Worker
Psychiatrist
Support Worker
Other
Organisation
Address
Postcode
Landline Telephone
Mobile
Email
Date of Referral
Day
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
13th
14th
15th
16th
17th
18th
19th
20th
21st
22nd
23rd
24th
25th
26th
27th
28th
29th
30th
31st
Month
January
February
March
April
May
June
July
August
September
October
November
December
Year
2035
2034
2033
2032
2031
2030
2029
2028
2027
2026
2025
2024
2023
2022
2021
2020
2019
2018
2017
2016
2015
2014
2013
2012
2011
2010
2009
2008
2007
2006
2005
2004
2003
2002
2001
2000
1999
1998
1997
1996
1995
1994
1993
1992
1991
1990
1989
1988
1987
1986
1985
1984
1983
1982
1981
1980
1979
1978
1977
1976
1975
1974
1973
1972
1971
1970
1969
1968
1967
1966
1965
1964
1963
1962
1961
1960
1959
1958
1957
1956
1955
1954
1953
1952
1951
1950
1949
1948
1947
1946
1945
1944
1943
1942
1941
1940
1939
1938
1937
1936
1935
1934
1933
1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
Your Support Needs
Describe briefly your mental health issues
What do you think would help you to manage your mental health and move towards recovery?
Support to increase physical activity.
Widen my social circle.
Somewhere to go when I feel overwhelmed or in crisis.
Learning new tools and techniques to improve my mental health and emotional well-being.
Being around nature.
Support and guidance around dementia and memory loss for people with dementia and their carers.
Support to explore and use creative skills and interests to help with my mental health and emotional well-being.
Help with finding out what other support is available in my community.
Are there currently any risks to yourself or others? E.g. self-harm, suicidal thoughts, violence to others, etc.
Please Select
Yes
No
If Yes, please give details, and whether or not this is a current risk. Please enclose a risk assessment, if you have one.
Have you Experienced Domestic Abuse,
Please Select
Yes
No
Is there anything else you think we should know? e.g. learning difficulties, alcohol/drug dependency
Do you have any access requirements e.g. disabilities, epilepsy, asthma, diabetes mobility, hearing or visual impairments, etc.
Your Current Support
GP Details
Please Select
Ashworth Street Surgery, 85 Spotland Road, Rochdale, OL12 6RT
Birtle View Medical Practice, George Street, Heywood , Rochdale, OL10 4PW
Castleton Health Centre, Elizabeth Street, Castleton, Rochdale, OL11 3HY
Durnford Medical Centre, 113 Long Street, Middleton, M24 6DL
Edenfield Road Surgery, Cutgate Precinct, Rochdale , OL11 5AQ
GP Care Services Ltd, The Willows Dementia Hub, Fieldway, off Broad Lane , Rochdale, OL16 4PP
HART (Homeless Alliance Response Team), The Old Post Office , No2 The Esplanade, Rochdale, OL16 1AE
Heady Hill Surgery, 114-116 Bury New Road, Heywood, OL10 4RG
Healey Surgery, Whitworth Road, Healey, Rochdale, OL12 0SN
Healthwatch Rochdale, 104 - 106 Drake Street, Rochdale, OL16 1PQ
Heywood Health, Argyle Street, Heywood, Rochdale, OL10 3SD
Hopwood Medical Centre, 1-3 Walton Street, Hopwood, Heywood, OL10 2BS
Inspire Medical Centre, Floor 2, The Croft Shifa Health Centre, Belfield Road, Rochdale, OL16 2UY
Junction Alkrington Surgery, 346 Grimshaw Lane, Middleton, Middleton, M24 2AU
Kingsway Practice (The), 285a Kingsway, Rochdale, OL16 4AT
Kirkholt Medical Practice, The Strand, Kirkholt, Rochdale, OL11 2JG
Littleborough Group Practice, Featherstall Road, Littleborough, Rochdale, OL15 8HF
Longford Street Medical Centre, Longford Street, Heywood, Rochdale, OL10 4NH
Mark Street Surgery, 2 Mark Street, Rochdale, OL12 9BE
Middleton Health Centre, Unit F1, Middleton Shopping Centre, Middleton, M24 4EL
Milnrow Village Practice, 44-48 Newhey Road, Milnrow, Rochdale, OL16 4EG
Peterloo Medical Centre, 133-135 Manchester Old Road, Middleton, M24 4DZ
Rochdale Community Mental Health Team, Sudden Resource Centre, Silk Street, Rochdale, OL11 3EU
Rochdale Road Medical Centre, 48a Rochdale Road, Middleton, M24 2PU
Stonefield Street Surgery, 21 Stonefield Street, Milnrow, Rochdale, OL16 4JQ
The Hive Health Centre, Clough Street, Middleton, M24 2YJ
Thinking Ahead, Lock 50 Business Centre, Oldham Road, Rochdale, OL16 5RD
Trinity Medical Centre, 22 Winton Street, Littleborough, Rochdale, OL15 8AR
Village Medical Practice (The), Peel Street, Littleborough, Rochdale, OL15 8AQ
Wellfield Health Centre, 116 Oldham Road, Rochdale, OL11 1AD
Windermere Road Surgery, 109-111 Windermere Road, Langley, Middleton, M24 5WF
Woodside Medical Centre, 247j Wood Street, Langley, Middleton, M24 5QL
York House Surgery, 19 York Street, Heywood, Rochdale, OL10 4NN
Yorkshire Street Surgery, 190 Yorkshire Street, Rochdale, OL16 2DN
The Family Practice, 133 Bowness Road, Middleton, M24 4EN
Dawes Family Practice, 83 Spotland Road, Rochdale, OL12 6RX
Nye Bevan House, Rochdale
Dale Medical Practice
Hollinwood Medical Centre
Dr Barbar's Surgery
Pennine Surgery, Featherstall Rd, Littleborough OL15 8HF
Newton Heath Health Centre
Not registered with a GP
Other
Landline Telephone
How did you hear about us?
How did you hear about us?
Please Select
Facebook
X
LinkedIn
Website
Leaflet/Flyer
Professional Service
Other
Emergency Contact Details
Name of person
Relationship to you
Address
Postcode
Mobile
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