Counselling Self-Referral Form
Referral Information
Referrers name:
Referrer's Contact Number
Identity
Forename
Surname
DateOfBirth
Address
Address1
Address2
Town
Post Code
Contact
Telephone
Mobile
Email
Preferred method of contact
Phone
Text
Email
Name and phone number of emergency contact
Demographic
Gender
Please choose a value
Female
Male
Trans
Non Binary
Other
Prefer not to say
Ethnicity
Please choose a value
Preferred Not to Say
Chinese or Other
White or White British
Mixed
Black or Black British
Asian or Asian British
Portuguese
Indian
White Candian
Polish
Irish
Not Known
Mixed Italian
Portugese/British
Polish Mother, British Father
Mexican mother
White
Romanian
Japan
Caucasian
Hungarian
Rusian
Italian
south african
Colombia
Scottish
French
Service Questions
Are you currently being supported by a mental health service or professional?
Please choose a value
Yes
No
If yes, please provide details.
Are there any needs or requirements that we should be aware of to help you access the service? (E.g. Medical conditions, mobility, hearing, visual, literacy, language etc)
Is there anything else you would like to tell
How did you hear about the service?
Please choose a value
Mind Jersey Website
Mind Jersey Social Media
Mind Jersey Peer Support Leaflet
Mind Jersey
Other Professional/Service
Other
If other or Mind Jersey, please give details
Please tell us what you would like support with and give specific examples if possible.
What is the current nature of your mental health difficulty, including diagnosis if diagnosed.
Name of GP and Surgery
Submit