Mind CHWF Services Referral Form

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Mind CHWF Services Referral Form

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This referral form is for Mind CHWF Services (including the Wellbeing Network) and should take 10-15 minutes to complete. The Wellbeing Network is for residents of City of London and Hackney boroughs. We ask a range of questions about your mental health and your life in general. The information you provide allows us to offer you the right services for your needs.

If you would like further information about the the Wellbeing Network please email us on wellbeingnetwork@mindchwf.org.uk.

If you would like access to the Wellbeing Network and need support to complete this form, please visit one of the Wellbeing Network partner organisations of your choice WBN partners

If you are at immediate risk please contact emergency services or go to A&E. For urgent support or if you are in crisis or distress please contact the City & Hackney Crisis Pathway Service 24 hour helpline on 0800 073 0006.

Privacy statement:

We want everyone who comes to us for support, to feel confident and comfortable with how any personal information you share with us will be looked after. This Privacy Notice Policy sets out how we collect, use, and store your personal information (this means any information that identifies or could identify you). Our Data Protection Officer makes sure we respect your rights and process your personal information according to the law. If you have any concerns or questions about how we look after your personal information, please contact the Data Protection Officer.

Are you are agreeing to our terms of service?(Required)

Unfortunately, we are unable to receive your referral without this consent. Please close the page to exit.

Please the service you would like to access:

Rainbow Mind - LGBTQ+ Service

IRIE Mind - Black African and Caribbean Services

Drugs/alcohol

Support for Suicide Loss

Suicide prevention training

Therapy

Education and Employment

Wellbeing Network

Select as many services that are relevant to you. Each box you tick will generate a referral to the relevant service..

If you selected Drugs/Alcohol support please also fill in this form Turning Point Referral Form, or get in contact 0345 144 0050

If you need additional services please keep filling out this form.

Referrer

Name of Wellbeing Network organisation

Referrer job title

Referrer contact name

Referrer's phone number

Referrer's email(Required)

Would you like to keep supporting the client while they are using our services?(Required)

Please select your GP

In case you are referring a client, please provide the client's GP practice

Do you consent for us to contact your GP?

In case you are referring a client, does the client consent for us to contact their GP?

Which Wellbeing Network organisation do you want to refer into?

We will make every effort to support this choice but it may not be possible in which case you will be allocated to another org but can still access groups from network providers.

During the course of accessing our services, we will need to contact you by telephone. If we are unable to get through, are you happy for us to: .

Leave a voicemail(Required)

Yes

Send a text(Required)

Yes

Send an email(Required)

Yes

We will contact you regarding your eligibility via email.

Support for you

Long term health condition

Bipolar Disorders

Personality Disorders

Psychotic disorders (schizophrenia, schizoaffective, etc)

PTSD

Are any of these life circumstances relevant?

Experience of trauma or abuse

Domestic abuse

Anxiety

Depression

Suicidal thoughts

Prior suicide attempts

Problems with housing and finance

Relationship breakdown

Loneliness or feeling isolated

Managing anger issues

Grief

Loss

Disordered eating

Discrimination

Refugee

Armed forces

Homelessness

Migrant Community

I want support with:

Taking notice of the present moment (rather than being lost in past or future)

Making healthy decisions and problem-solving

Connecting meaningfully with others

Giving back to others

Building healthier habits (nutrition, managing health issues, cutting down on substances such as alcohol, drugs and smoking)

Being physically active

Learning new skills

Creating purpose and meaning in my life

How will this referral support your care plan for this client? .

Reasons for referral

If you are making this referral on behalf of a client please state how it will support the clients care plan

Contact details

Please enter the clients contact information.

Title

First Name(Required)

Surname/Family Name(Required)

Pronouns

Other Pronouns

House number (Flat number, building) and street

City

Postcode

Borough(Required)

Wellbeing Network is only able to work with people from City and Hackney

Country

Phone Number(Required)

Please enter the mobile number without spaces

Email address

Demographic details

Date of Birth(Required)

Gender

Prefer to self-describe

We provide specific services for key demographics in City and Hackney. Would you describe your heritage as:(Required)

What is your ethnicity?

Is English your first language?

Sexual orientation

Sexual orientation self-description

Religion

Do you consider yourself to live with any of the following that you would like to make us aware of?

Learning Disability

Physical Disability

Mental Health Condition

Autism

Prefer not to say

Other

Do you provide unpaid care/support to someone for at least an hour a week?(Required)

Were you born out of the UK?(Required)

Rainbow Mind – LGBTQ+ Services Available

Rainbow Room online - a fortnightly, young LGBTQ+ online space to connect, share and explore mental health and wellbeing.

The Gatherings online - monthly workshops online on topics such as Love, Loss, Imperfection, Challenging Emotions, Connection.

Radical Self-Care courses- An 8 Week RadSec course combinating of experiential practices, psycho-education and invitational group discussion about the exercises.

ACT Course (Acceptance and Commitment Therapy) - online course supports us to develop awareness of ourselves through guided practices and psychological flexibility, nurturing a compassionate relationship with ourselves. ACT is best suited to those experiencing mild to moderate anxiety or depression.

Which support would you be interested in accessing? Please tick as many options as you would like.

ACT Course

Connect Groups

One to One Talking Therapy

Radical Self-Care Courses

Rainbow Room online

The Gatherings online

Webinars

African & Caribbean mental health additional information.

We offer support in the following areas, please choose as many as you need

Benefits Advice

Counselling

Hearing Voices Group

Information and Advice

IRIE Mind Front Room

Men's Group

Nyam N Go Cooking

Peer Mentoring

Telephone Befriending

This Gyal Can (16-25 year olds)

Tree of Life

Women's Group

Mental Health Diagnosis

Other mental health diagnosis

Current prescribed medication

Any active substance/alcohol abuse?

Any major risks at time of referral?

Benefits & money troubles aditional information

Do you have any dependent children?

Do you have any children under two?

Are you currently pregnant?

Do you currently smoke?

Suicide loss bereavement aditional information

We will only contact this person in the case of an emergency and if it is possible will notify you before we do.

Emergency contact full name

Relationship to you

Phone

Emergency contact email

Emergency contact address

Education and Employment aditional information

Nationality

Please click on the education support you would like to receive:

Computers / IT

English / Literacy

ESOL (English as a second language)

Maths

Please click on the employment support you would like to receive:

Help gaining qualifications

Help getting a job

Managing workplace difficulties and stress

Support to become a volunteer

Filling out the following questionnaires will help us to determine the right kind of support for you, if you would prefer to discuss them with a member of our team please leave them blank and submit your referral

Below are some statements about feelings and thoughts.

Please enter the number that best describes your experience of each over the last 2 weeks based on the below:

= None of the time
= Rarely
= Some of the time
= Often
= All of the time

I have been feeling optimistic about the future(Required)