Referral Form I'm making a referral on behalf of(Required) Myself Someone else The service required is in:(Required)Select area...East RenfrewshireRenfrewshireNorth AyrshireEast AyrshireThe following service(s) is/are required: Community Services Counselling Community Link Employability Housing Support Youth Counselling Information I'm not sure Please refer to the Healthier Minds Service. You do not need to complete this referral form.The following service(s) is/are required: Community Services Employability Housing Support Information FIRST Crisis I'm not sure The following service(s) is/are required: Recovery College I'm not sure Personal details - About the person being referredFirst name(Required)Last name(Required)Date of birth(Required)DayDay12345678910111213141516171819202122232425262728293031MonthMonth123456789101112YearYear202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender(Required)NI NumberAddress(Required)Postcode(Required)Mobile number(Required)Home telephone numberEmail address Please provide name, address and contact details of Next of KinEthnicity(Required) Asian or Asian British Black or Black British White or White British Mixed Background Other How may we contact you?Please tick all of the ways we can get in touch. Mobile no Leave a message OK to identify Service SMS / Text message Home no Letter to home Email consent Other supporting organisationsAgencyContactTelephone number Add RemoveName of GP practiceGPGP telephone numberCHI NumberLiving arrangements Carer role in household Caring for children Living alone Living in homeless unit Living in residential/secure accommodation Living in supported accommodation Living with foster carer Living with parents/guardian Living with partner Living with other relatives/friends Looked after at home Other Are there any children in the home? Yes No Please provide detailsDoes the person have any medical/mental health conditions? Yes No Not sure Do you have any medical/mental health conditions? Yes No Please provide detailsIs the person taking any form of medication? Yes No Not sure Are you taking any form of medication? Yes No Not sure Please provide detailsReferrer detailsReferrer full name(Required)Relationship to service user(Required)Address (including postcode)(Required)Contact phone number(Required)Email address(Required) Referral detailsIs the person aware of the service and in agreement to the referral? Yes No Is the person willing to attend the service? Yes No Reasons for referral - (summary of your reasons for referring for support)(Required)Please include details, including support guidelines or action to be taken if RAMH staff have any concernsHave you discussed Self Directed Support (SDS) options? Yes No Which SDS options have you discussed? SDS Option 1 SDS Option 2 SDS Option 3 SDS Option 4 Please check all of the reasons that best describe why support is needed at this timePlease tick all that apply. Abuse Addiction to drugs/alcohol Adverse childhood experiences Anger issues Anxiety/stress Bereavement/loss Bipolar illness Bullying Carer Cognitive/learning COVID Depression Eating issues Family issues Gambling harm Interpersonal/relationship difficulties Living/welfare/housing Loneliness Low Mood Personality/challenging behviour Physical health/illness Pregnancy Psychosis School issues Self-esteem Self-harm Suicidal intention/behaviour Trauma Work/academic/training Other Please tell us other reasons for supportPlease tell us other reasons for supportRisk assessment, safeguarding or protection issuesDo you know of any areas of risk/concern that RAMH should be aware of?(Required) Yes No Please provide details, including guidance on what action RAMH should take if we are unable to make initial contact with the service user egย who else can we make contact with?(Required)Your dataRAMH 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.Please confirm you have read the statement above(Required) I understand Are you a RAMH staff member?Please check if you are a RAMH staff member recording details of a referral I am a RAMH staff member Risk assessment, safeguarding or protection issuesPlease 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?
