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By completing this referral form you agree and consent to sharing information with the Haringey Wellbeing Network and connected professionals to access our services and/or be linked to the best-placed support according to your needs. We will also use this information for health and safety purposes and to evaluate and improve our services. Information provided will remain confidential and will be held on a computerised and paper-based systems, in accordance with the General Data Protection Regulation (GDPR. Further details can be found on our website.

The Haringey Wellbeing Network is a mental health and wellbeing community support service, meaning we are UNABLE to help with legal and housing-related matters, however, we are able to refer you to legal or housing-related support services. We specialise in providing emotional support and promoting community engagement with a vision to increase wellbeing

About you (Or for third party referral: About the referred individual)

Do you currently have a care co-ordinator?

Do you have an address or GP in Haringey?

Do you have any spent or unspent criminal convictions?

Identity

Title

Forename

Surname

Also Known As

Preferred Pronouns

Date Of Birth

Primary Language

Interpreter Required?

NHS Number

National Insurance Number

Contact

Mobile

Telephone

Address 1

Address 2

Town

County

Post Code

Emergency Contact / Next of Kin

GP details

Demographic

Gender

Is your gender the same as the gender you were assigned at birth

Ethnicity

Nationality

Religion

Sexuality

Marital Status

Is this Service User a Carer?

Refugee Status

Employment Status

Disability

Yes No Unknown None

Are you in receipt of welfare benefits? (Please tick all that apply)

Service Related Information

Housing related concerns

We ask everyone about gambling because it can sometimes affect wellbeing. Has gambling (by you or someone close to you) ever affected your wellbeing, relationships, or finances?

Do you have a diagnosed mental health condition? (Please leave details)

Have you ever been detained/ sectioned under the Mental Health Act?

Are you currently receiving mental health support?

Mental Health Support

Do you have any access needs we should know about?

Do you have any criminal convictions? (Please note answering yes is not a disqualifying factor)

Have you accessed another Mind in Haringey Service before?

What support would you like to receive from Mind in Haringey?

The GP Federation provide annual Physical Health check’s – Is this something you would be interested to learn more about?

At Mind in Haringey we deliver a Free 2-day Mental Health First-Aid Training course – would you like to learn more about this offer?

Please describe your immediate need

What outcomes would you like to achieve by accessing our Mental health service?

Do you have any triggers that influence your behaviour negatively? (Cause you to become aggressive, withdrawn, induce a panic attack?) If yes, please specify

What are the signs/symptoms that your mental health/wellbeing is deteriorating, or that you are becoming unwell?

How did you hear about Mind in Haringey?

Referral completed by:

Professional Name & Organisation/Agency

Professional referral agency contact details:

WELLBEING QUESTIONNAIRE - For each of the 14 statements below, please indicate on a scale of 1-5 (1=None of the time, 2= Rarely, 3= Some of the time, 4=Often, 5=All of the time) how often you have felt this way over the past two weeks.

I’ve been feeling optimistic about the future

I’ve been feeling useful

I’ve been feeling relaxed

I’ve been feeling interested in other people

I’ve had energy to spare

I’ve been dealing with problems well

I’ve been thinking clearly

I’ve been feeling good about myself

I’ve been feeling close to other people

I’ve been feeling confident

I’ve been able to make up my own mind about things

I’ve been feeling loved

I’ve been interested in new things

I’ve been feeling cheerful

Consent

Consent to share information with other Professionals

Consent to Receive Further Communication?

Consent to Participate?

I consent, in accordance with the General Data Protection Regulation (GDPR) to being fully informed about the referral being made

For third-party referrals: has the referred individual consented to this referral being made on their behalf?