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Mind in Havering, Barking & Dagenham- Referral Form

Before completing this form, please note:

Our service is not able to provide an immediate response or support in an emergency/crisis. If you require immediate urgent help, please contact the NELFT 24-hour Mental Health Direct at 0800 995 1000.

Essential Project Criteria:

Only select ONE service when completing this form - multiple choices cannot be considered.

Meaningful Activities Program - Professional Referrals Only.

Mums Matter - Must have at least one child aged 2 and under. 

Ready for Adulthood - 17 - 25yrs; 

Identity

Contact

Demographic

Address

Presenting Issues

Service Related Information

Referral Information

GP Information

Emergency Contact

Consent

Other Information

To be completed for Parent Support Group

Client Consent

By submitting this referral form, I give permission for Mind in Havering Barking & Dagenham staff to contact my emergency contact, GP or mental health worker in the event that there is a cause for concern surrounding my health and well-being needs or there is an emergency situation.  I understand that this will mean some sharing of appropriate information.

In order to help you we need to store information about you.  Everything you tell us will be treated confidentially in line with our policy.

I consent to the following statements: 

1) I give my consent for Mind Havering Barking and Dagenham to contact relevant third parties on my behalf.  Your agreement will be sought before we make contact with others about you, unless it is an emergency situation.

 2) I give my consent for Mind to contact me via one or all of these methods: Phone, SMS/ Text, Email, Post.

If you have an email address, it would help to reduce our costs if we can contact you via email.

By sharing these details and requesting to join any of our groups/services, you also agree to comply with our Client Participation and Involvement Policy, available upon request.

You can withdraw your consent or change your mind at any time. You can find more information in our Privacy Notice. We can provide a hard copy on request.

Please confirm the following details are correct

Identity

Contact

Demographic

Please Select
Please Select
Please Select
Please Select
Please Select
Please Select
Please Select

Address

Presenting Issues

Please Select
Please Select
Please Select

Service Related Information

Please Select
Please Select
Please Select
Please Select

Referral Information

Please Select

GP Information

Please Select
Please Select

Emergency Contact

Please Select
Please Select

Consent

Please Select
Please Select
Please Select
Please Select

Other Information