Mental Health Connect Referral Form

Full Name

Referral Date

Method of referral Method of referral Email Telephone

Address Line 1

Address Line 2

Town/City

Postcode

Date of Birth

Gender GenderMale including trans maleFemale including trans femaleNon-binaryNot statedNot knownOther

NHS Number

Phone Number

Reason for Referral

Email

Concerns/Notes - please inform is of any safeguarding issues

Name of referrer

Job Role

Work Phone

Work Email

Please confirm that the client/customer has given consent, MUST be completed for referral to be accepted. Please confirm that the client/customer has given consent, MUST be completed for referral to be accepted. I consent to my name, contact details and the personal information on this form being shared with appropriate staff members within Mental Health Connect, this could be Roshni Ghar, Missing Peace, Keighley Healthy Living and Project 6. All information will be stored securely on COMPASS and MYMUP and in compliance with GDPR requirements and will be stored for 60 months as outlined in the relevant privacy policy.

Ethnicity Ethnicity Which of the following options best describes your race, ethnic or cultural origin: White English / Welsh / Scottish / Northern Irish / British White Irish White East European White Other Mixed White / Black Caribbean Mixed White / Black African Mixed White / Asian Mixed Other Asian or Asian British Indian Asian or Asian British Pakistani Asian or Asian British Bangladeshi Asian or Asian British Kashmiri Asian or Asian British Other Black or Black British Caribbean Black or Black British African Black or Black British Other Chinese Roma Arab Gypsy / Traveller Other Don’t Know

Do they have a disability? Do they have a disability? Yes No

Are they a carer? Are they a carer? Yes No

Please let us know the best contact method for the client: (select all that apply, MUST select one for referral to be accepted) Please let us know the best contact method for the client: (select all that apply, MUST select one for referral to be accepted) Email Telephone Can we leave a voicemail Text Post