Wellbeing Referral Form

Can you get to the group on your own?

Coming to a group for the first time can be nerve racking, do you feel able to give it a try?

Have you looked at all the groups we offer, which interests you the most?

Is there anything staff can do to help you get through the door and join a group? Please share this with staff if you decide to make contact.

Referral made by:

Self
GP
Other professional - please give details

Other professional details

Title

First Name(s)

Surname

Preferred Name/Name like to be known as

This could be a nickname you prefer, or an additional name you may like to go by.

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Landline

Mobile

Email

Please note: we require a telephone number or email address to contact you about your referral. If you don’t wish to share details of both, write 'N/A' in the box that you'd like to leave blank.

Can we contact you by the following means? Please tick all that apply

Text
Phone
Email
Post

Information About You

Have you been known by any other name, or do you work with any other services that know you by any other names? If so, please let us know.

Date of birth

Gender

Your Pronouns

He/him
She/her
They/them
Other (please specifiy)

Pronouns are used in place of a proper noun (like someone’s name). We use pronouns most often when referring to someone without using their name.

How would you describe your relationship status?

If Other, please specify:

First Language

Ethnicity

What is your employment status?

If part time, how many hours do you work in a typical week?

Do you receive benefits?

If so, which ones?

Do you have a carer?

Are you a carer for someone?

Are you a care leaver?

Do you consider yourself disabled?

If so, please describe your disability. You may select more than one.

Physical Condition (such as a substantial or long-term condition affecting a part of a person’s body that impairs and limits their physical functioning, mobility, stamina or dexterity includes using a wheelchair or crutches)
Sensory Condition (such as when one of your senses; sight, hearing, smell, touch, taste and spatial awareness, is no longer normal)
Mental health condition, (such as depression or anxiety)
Learning disability/difficulty (such as Down’s syndrome or dyslexia)
Cognitive condition (such as autistic spectrum disorder)
Long-standing illness or health condition such as cancer, HIV, diabetes, chronic heart disease, or epilepsy
Prefer not to say

What is the main reason you have for coming to a group? (please tick one)

Please state what other help you may be looking for

Currently registered with or receiving support from any other service?

If yes, please provide further information on that service

Information about your GP/Surgery

GP Practice you are currently registered with

Name of your GP

Emergency Contact Details

Full Name

Phone Number

Emergency Contact Email

Relationship to you

In case of an emergency, do you give us permission to discuss your records with them?

Is there any other relevant information you would like us to know?

Would you like to sign up to receive monthly updates from Bath Mind including wellbeing tips, upcoming events and courses, and charity news?

Yes
No

CONFIDENTIALITY & DATA PROTECTION

Bath Mind is committed to maintaining client confidentiality. All information about you is held securely and not shared with anyone outside our organisation without your permission, or unless exceptional circumstances occur. If you wish to see the records we hold about you this can be arranged by request to the Chief Executive Officer of Bath Mind. If we believe there is a risk of harm to you or someone else we will inform the appropriate person (such as your GP or other health professional), but we would always endeavour to discuss this with you in advance.

For further information please view our Privacy Policy

Declaration
I understand and have read, Bath Minds Privacy Policy. I declare that the information provided by me is accurate to the best of my knowledge.

If I choose to go ahead and access the services provided by Bath Mind, I hereby authorise Bath Mind to store personal information related to me and the service I receive.

If you are happy to accept the above terms and conditions please tick the following box and click on the button marked submit.

Single Checkbox Field

I am happy to accept the above terms and conditions.

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Wellbeing Services Referral Form

Information About You

Information about your GP/Surgery

Emergency Contact Details

CONFIDENTIALITY & DATA PROTECTION

Wellbeing Services
Referral Form