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Step 1 of 4
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 email@example.com.
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.
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.
Unfortunately, we are unable to receive your referral without this consent. Please close the page to exit.
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.
If you have selected “Suicidal thoughts”, we offer a safe space for people to talk about their feelings and explore the underlying reasons as to why someone may feel suicidal. You can call the Safe Connections Hub helpline on – 0300 561 0115.
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:
How will this referral support your care plan for this client?
Please enter the clients contact information.
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.
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: