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
Female
Male
Not stated
Other
Prefer not to say
Transgender
Ethnicity
Please choose a value
African
Algerian
Any other Asian background
Any other Black background
Any other ethnic group
Any other mixed background
Any other white background
Bangladeshi
Black or Black British
British/Dutch
Caribbean
Chinese
Gypsy or Traveller
Indian
Pakistani
Sri Lankan
Syrian
Turkish Cypriot
White and Asian
White and Black African
White and Black Caribbean
White British
White Irish
Unknown
Prefer not to say
Not stated
Portuguese
Arabic
Turkish
Somalian
Iranian
Filipinno
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:
In Case of Emergency contact
In Case of Emergency (ICE) Name
ICE phone number
ICE relationship to the Client
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