Make a referral

The service required is in:(Required)

Please refer to the Healthier Minds Service. You do not need to complete this referral form.

Personal details - About the person being referred

First name(Required)

Last name(Required)

Gender(Required)

NI Number

Address(Required)

Postcode(Required)

Mobile number

Home telephone number

Email address

Please provide name, address and contact details of Next of Kin

Name of GP practice

GP

GP telephone number

CHI Number

Please provide details

Referrer details

Referrer full name(Required)

Relationship to service user(Required)

Address (including postcode)(Required)

Contact phone number(Required)

Email address(Required)

Referral details

Reasons for referral - (summary of your reasons for referring for support)(Required)

Please include details, including support guidelines or action to be taken is RAMH staff have any concerns

Please tell us other reasons for support

Risk assessment, safeguarding or protection issues

Please provide details, including guidance on what action RAMH should take if we are unable to make initial contact with the service user eg who else can we make contact with?(Required)

Your data

RAMH operates a confidential and secure service and is registered under the Data Protection Act and are GDPR Compliant. The information you provide will be processed by computer. You may have access to information on written request. RAMH is a charity registered in Scotland No SC0 10430 and is a Company Limited by Guarantee No 141458.

Are you a RAMH staff member?

Risk assessment, safeguarding or protection issues

Please provide details, including guidance on what action, e.g. FIRST Crisis should take, if they are unable to make initial contact with the service user, is there anyone you would like us to contact?

Referral Form

Personal details - About the person being referred

Referrer details

Referral details

Risk assessment, safeguarding or protection issues

Your data

Are you a RAMH staff member?

Get in touch

Quick links

Access support