Active Minds Referral for BSL Members
Identity
Forename
Nickname
Surname
DateOfBirth
Address
Address 1
Address 2
Town
County
Post Code
Demographic
Gender
Please choose a value
(Do not use )Transgender (Do not use)
All Other Gender Identities
Female
Male
Non-binary
Not stated
Prefer not to say
Trans Man
Trans Woman
Ethnicity
Please choose a value
Asian Other
Black Other
Arab
Asian Bangladeshi
Asian Chinese
Asian Indian
Asian Pakistani
Black British African
Black British Carribean
Mixed Other
Mixed White and Asian
Mixed White and Black African
Mixed White and Black Caribbean
Other ethnic group
Prefer not to say
Unknown
White British
White Gypsy or Irish Traveller
White Irish
White Other
White Roma
Contact
Telephone
Mobile
Email
Service Related Information
Communication Restrictions?
Please choose a value
Yes
No
Unknown
Additional Notes including access requirements
Other Information
Description of mental health i.e. relapse indicators, triggers
How/where did the person hear about the service?
Another Mind Service
Carers information Centre
SLAM
Croydon JCP
ctrp
Enron review
Friend
gp
Gresham 2 ward
Hear Us
Housing Association
Internet
JCP
lantern hall
MH forum or meeting
off the record
other support worker
Out of Borough Support Agency
Palmer House
Porchlight
Previous use of service
Psychologist IAPT
River House, Bethlem
Self Referral
Social Worker
South London Maudsley
South London YMCA
STR worker
The Maudsley Hospital
TV / Press / Radio
Unknown
Voluntary service
Website
Please give contact details for professional support received
Do you give consent to contact these professionals?
Yes
No
Is there any additional support you require?
The last 3 months, have you had any support for mental health?
GP
Supported housing
Probation service
Community treatment team
Care Coordinator
Drug or alcohol services
Social Services
Other Mind Service
MHPIC
Other
None of the above
Consent
Consent to Receive Further Communication?
Please choose a value
Yes
No
Unknown
Referrer Details
Referrer Name
AM Referrer address
AM Referrers Email:
AM Referrer landline phone number
AM Referrers Mobile Phone Number:
Health questions
Has your doctor ever said you have a heart condition?
no
yes
Do you ever get chest pains?
no
yes
Do you have a bone or joint problem?
no
yes
Do you lose your balance, get dizzy, or ever lost consciousness?
no
yes
Do you take blood pressure medication?
no
yes
Do you have any other condition made worse through activity?
no
yes
If you've ticked yes to any health question, please give details
Submit