Rochdale & District Mind Referral Form
Identity
Prefer to be known as
Gender
Please choose a value
Female
Male
Non-binary
Other
Prefer not to say
Forename
Surname
Date Of Birth
Day
1st
2nd
3rd
4th
5th
6th
7th
8th
9th
10th
11th
12th
13th
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19th
20th
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22nd
23rd
24th
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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
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1993
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1991
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1989
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1982
1981
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1968
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1932
1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
1919
1918
1917
1916
1915
1914
1913
1912
1911
1910
Language
Please Select
English
Urdu
Punjabi
Bengali
Polish
Portuguese
Kurdish
Other
Other
Do you need an interpreter?
Please choose a value
Yes
No
Address 1
Address 2
Town
County
Post Code
Are we okay to send a letter?
Please choose a value
Yes
No
Landline Telephone
Are we okay to leave a message one the landline?
Please choose a value
Yes
No
Mobile
Are we okay to leave a message?
Please choose a value
Yes
No
Are we okay to text?
Please choose a value
Yes
No
Email
Are we okay to Email
Please Select
Yes
No
Monitoring Information
Ethnicity
Please Select
White - British
White - Irish
White - Eastern European
White - Other
Black - African
Black - Caribbean
Black - Other
Asian - Pakistani
Asian - Bangladeshi
Asian - Chinese
Asian - Indian
Asian - Other
Mixed - Black Caribbean and White
Mixed - Black African and White
Mixed - East Asian and White
Mixed - Other
Other - Arab
Other - Other ethnic group
Do not wish to state
Asian - Japanese
Black African and East Asian
Black African and South Asian
Black Caribbean and East Asian
Black Caribbean and South Asian
Mixed - South Asian and White
Other - Gypsy or Traveller
How would you describe your religious beliefs?
Please Select
No religion affiliation or belief
Christianity
Buddhist
Hindu
Muslim
Jewish
Sikh
Do not wish to state
Other
Other
How would you describe your sexual orientation?
Please Select
Heterosexual
Bisexual
Lesbian
Gay
Do not wish to state
Other
Other
Demographic and Monitoring
Have you Experienced Domestic Abuse,
Please Select
Yes
No
Monitoring Information
How would you describe your relationship status?
Please Select
Married
Co-habiting
Single
Civil partnership
Do not wish to state
Other
Other
How would you describe your residency status?
Please Select
British Citizen
EU National
Refugee
Asylum Seeker
Do not wish to state
Other
Other
Are you a veteran? (ex-service person)
Please choose a value
Yes
No
Do not wish to state
Are you a Carer?
Please choose a value
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
Other
Details of Referrer
Are you completing this form for yourself?
Please Select
Yes
No
Referrers name:
Role
Please Select
Advocate
Alcohol / Drug Worker
CPN
Counsellor / Therapist
Employment Advisor
GP
Occupational Health Advisor
Probation Worker
Psychiatrist
Support Worker
Other
Other
Organisation
Address
Postcode
Landline Telephone
Mobile
Email
Mental Health Issues
Describe briefly your mental health issues
Depression
Anxiety
Stress
Other
If other, please provide details
Your Support Needs
What do you think would help you to manage your mental health and move towards recovery?
Self Help Courses
Support Groups
Creative Groups
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
Not registered with a GP
Other
Other
Landline Telephone
Issues
Any physical issues you think we should know about e.g. disabilities, epilepsy, asthma, diabetes
Any other issues you think we should know about e.g. learning difficulties, alcohol/drug dependency, pregnancy
Risk Issues
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, theft?
Please choose a value
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.
Submit
