Wellbeing Network Referral Form

Step 1 of 4

This referral form is for The Wellbeing Network and should take 10-15 minutes to complete. The Wellbeing Network is for residents of City of London and Hackney boroughs. As a principle we accept re-referrals from people who have been discharged from the Wellbeing Network at least 6 months ago. 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 please email us on wellbeingnetwork@mindchwf.org.uk.

The Wellbeing Network only works in English across organisations. Derman can provide support to Turkish speaking people and Bikur Cholim can provide support to Hebrew speaking people.

If you 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 Mental Health Crisis Support. Please call NHS 111, and press 2 for Mental Health Support.

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.

Referrer

Name of Wellbeing Network organisation

Referrer job title

Referrer contact name

Referrer's phone number

If no phone number please leave blank

Referrer's email(Required)

Will you continue to support this client over the next 6-12 month and agree to help the client register (via our website) onto WBN courses and groups?(Required)

You are making a Shared Care referral to the Wellbeing Network (WBN).

This means you will keep working with the person you are referring, even after they start getting support from us.

By making this referral, you agree to:

Complete the assessment with the person before they start accessing the WBN.
Support them to register interest in WBN courses (via our website).
Complete a review at three months.
Complete an exit review at nine months, or at any point when the person decides to exit the service.

Shared Care means that key partners can support people to access the WBN as part of their existing support plan.

Why did you select the "No" option in the previous question?

255 Maximum Characters

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?(Required)

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. For information about the Wellbeing Network Organisations please click WBN partners .

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.

Wellbeing Network Referral Form

Support for you

Contact details

Demographic details

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

Over the last week, how often have you been bothered by any of the following problems?