Initial Contact - Generic
Identity
Forename
Surname
Date Of Birth
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
2036
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
Address
Address 1
Address 2
Town
County
Post Code
Contact
Telephone
Mobile
Email
Demographic
Gender
Please Select
Female
Male
Other (please define)
Non-binary
Prefer not to say
Gender - Other
Ethnicity
Please Select
Asian or Asian British - Bangladeshi
Asian or Asian British - Chinese
Asian or Asian British - Indian
Asian or Asian British - Japanese
Asian or Asian British - Other
Asian or Asian British - Pakistani
Black or Black British - African
Black or Black British - Caribbean
Black or Black British - Other
Mixed - Asian & White
Mixed - Black African & East Asian
Mixed - Black African & South Asian
Mixed - Black African & White
Mixed - Black Caribbean & East Asian
Mixed - Black Caribbean & South Asian
Mixed - Black Caribbean & White
Mixed - East Asian & White
Mixed - Other
Mixed/Multiple Ethnic Groups - White and Chinese
Not stated
Other - Another background
Other - Arab
Other - Gypsy or traveller
Prefer Not To Say
White or White British - Eastern European
White or White British - Other
White or White British - White British
White or White British - White Irish
Religion
Please Select
Buddhist
Christianity
Hindu
Jewish
Muslim
No religion
No religion affiliation or belief
Other (please specify)
Prefer not to say
Sikh
Does the client have a disability?
Please Select
Yes
No
Prefer not to say
Disability (specify)
Please Select
Deafness/Partial Loss of Hearing
Blindness/Partial Loss of Sight
Learning Disability
Learning Difficulty
Development Disability
Physical Disability
Long Term Ilness
Mental Health
Autistic Spectrum Disorder
Behaviour & emotional
Hearing
Manual dexterity
Memory or ability to concentrate, learn or understand (Learning Disability)
Mobility & gross motor
Perception of physical danger
Personal, Self care & continence
Progressive conditions & physical health (eg. HIV, cancer, fits, MS etc.)
Sight
Speech
Prefer not to say
Other
Other
Sexuality
Please Select
Asexual
Bisexual
Gay
Heterosexual
Lesbian
Other
Prefer not to say
Nationality
Please Select
British
English
Welsh
Northern Irish
Scottish
Prefer not to say
Other
Presenting Issues
Please state any ongoing physical health problems?
Does this physical health problem require medication?
Reason for contact
Referral Information
Type of Referral
Please Select
Self
Agency
Referral Agency
Please Select
B&D Referer
BHRUT
CAMHS
CLDT
Community Recovery Team
DWP
Early Help
GP
HAABIT
Havering Mind
Havering Mind CCG
LBH Social Services
MASH
OOB- Local Authority (IMCA)
Other NELFT Services
Other community / voluntary sector
Pause
Richmond Fellowship B&D
Richmond Fellowship Havering
Schools
Social Prescriber
Talking Therapies Havering
Name of Referrer
Position of Referrer
Emergency Contact
Emergency Contact
Please Select
Yes
No
Emergency Contact - Name
Emergency Contact - Telephone
Emergency Contact - Permission to Contact?
Please Select
Yes
No
Any other action required incase of emergency? Please specify...
Other Information
How/where did the person hear about the service?
Existing Stakeholder
External agency
Family support worker
Health Practitioner
In House
Local Media
Mental Health Social Worker
Other Minds
Previously A Client
School
Self Referred
Website
Word of Mouth
What outcome would you like from this service?
Consent
Consent to Receive Further Communication?
Please Select
Yes
No
Prefer not to say
Consent to Participate?
Please Select
Yes
No
Prefer not to say
Photographic Consent ( For promotional and documentary purposes e.g. Mind publications, social media, third party sources)
Please Select
YES
NO
partial photo consent see media file
Submit