Mind In Camden
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Healthy Minds Community Programme Referral Form
Healthy Minds Community Programme Referral Form
Personal Details
Name
*
First name
Surname
Preferred name
Date of birth
Date Format: DD slash MM slash YYYY
Gender
*
Male
Female
Transgender
Email
Phone - mobile
Phone - landline
Address
*
Street Address
City
Post Code
Preferred method of contact
*
Mobile
Landline
Email
Post
Would you like to receive our email newsletters?
*
Yes
No
Would you like to receive our text message updates?
*
Yes
No
Emergency contact
Emergency contact name
*
First name
Surname
Contact number
Relationship
Additional information
Ethnicity
*
Please choose form the dropdown list below:
White: English/Welsh/Scottish/Northern Irish/British
White: Irish
White: Gypsy/Irish Traveller
White: Other White background
Mixed: White & Black Caribbean
Mixed: White & Black African
Mixed: White & Asian
Mixed: Other Mixed
Asian/Asian British: Indian
Asian/Asian British: Pakistani
Asian/Asian British: Bangladeshi
Asian/Asian British: Chinese
Asian/Asian British: Other Asian
Black/African/Caribbean/British: African
Black/African/Caribbean/British: Caribbean
Black/African/Caribbean/British: Other
Other Ethnic Group: Arab
Other Ethnic Group: Other
Self assessment
Do you identify yourself as having physical or learning needs?
*
Yes
No
You answered 'Yes'. Please could you provide us with more detail to ensure we can best support you
*
Do you identify yourself as having mental health needs?
*
Yes
No
You answered 'Yes'. Please could you provide us with more detail to ensure we can best support you
*
Referrer details
Referrer or Care Coordinator?
Referrer
Care Coordinator
Name
First
Last
Address
*
Street Address
City
Post Code
Email
Contact number
Cluster
(if applicable)
Psychosis Services (Recovery & Rehabilitation)
Services for Ageing and Mental Health (SAMH)
Psychosis Services (Outreach)
Non-Psychosis Services (Community Mental Health
When I have difficult days with my mental or physical health, is there anything I struggle with in particular?
*
e.g: My sleep, my mood, my self-care, suicidal thoughts, anger
Are there any triggers which make things worse for me and how best can these be managed?
What risks can I present to myself or others (if any)?
What helps me?
I agree that Mind in Camden may need to share information from this form, and any concerns regarding my health or welfare with partner organisations who I engage with through Healthy Minds, and/or named professional.
*
You will need to agree to the above for the form to be submitted.
I agree
I don't agree
Phone
This field is for validation purposes and should be left unchanged.
The REST project has moved
Cultural Advocacy Project
Phoenix Wellbeing & Recovery Service
Healthy Minds
Healthy Minds Community Programme Referral Form
Healthy Minds Community Programme
Pre Questionnaire
The Short Warwick-Edinburgh Mental Well-being Scale
What’s On at Healthy Minds
Voices Unlocked
Hearing Voices: Refugees and Asylum Seekers
London Paranoia & Beliefs Network
Voice Collective Youth Project
Mind in Camden Social Prescribing Services
London Hearing Voices Network
Mental Health Training & Consultancy
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