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. 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.

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 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.

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

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

Please enter the clients contact information.

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:

1. = None of the time
2. = Rarely
3. = Some of the time
4. = Often
5. = All of the time