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Referral Form

I'm making a referral on behalf of(Required)

Myself

Someone else

The service required is in:(Required)

The 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 referred

First name(Required)

Last name(Required)

Date of birth(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

Ethnicity(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 organisations

Agency

Contact

Telephone number

Name of GP practice

GP

GP telephone number

CHI Number

Living 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 details

Does the person have any medical/mental health conditions?

Yes

No

Not sure

Do you have any medical/mental health conditions?

Yes

No

Please provide details

Is the person taking any form of medication?

Yes

No

Not sure

Are you taking any form of medication?

Yes

No

Not sure

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

Is 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 is RAMH staff have any concerns

Have 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 time

Please 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

Interpersonal/relationship difficulties

Living/welfare/housing

Loneliness

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 support

Please tell us other reasons for support

Risk assessment, safeguarding or protection issues

Do 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 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.

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 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?

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