Title * MrMrsMissDrOhther
Gender MaleFemaleOtherPrefer not to say
Date of Birth *
Name *
Surname
Address (including post code) *
Telephone Number
Mobile
Email
Please tick if you DO NOT wish to receive updates about RF news and service
Reason for referral & what would you like to achieve?
What do you feel we need to know about your wellbeing and physical/mental health?
Supporting statement (optional)
Professionals Involved
Self referral YesNo
Where did you hear about our service?
Referrer?s Address (including postcode)
Telephone
Are you currently accessing any mental health services? YesNo
If so, which service are you accessing?
Is there a current risk assessment available? YesNo
If yes, please include where appropriate
Mental Health Professional/Organisation:
GP Practice Name
White BritishIrish Traveller of Irish heritageGypsy/RomaOther white
Mixed White & Black CaribbeanWhite & Black AfricanWhite & AsianOther mixed
Asian / Asian British IndianPakistaniBangladeshiOther Asian
Black / Black British CaribbeanAfricanOther Black
Chinese / Other ChineseOther (any)RefusedNot yet obtained
Disability and Carer status (please circle) NonePhysicalVisual ImpairmentHearing ImpairmentDual SensoryLearning DisabilityAutism
Are you a carer? YesNo
Religion Christianity - All denominationsIslam - All denominationsHinduism - All denominationsJudaism - All denominationsBuddhism - All denominationsSikhism - All denominationsAll Astronomy based faithsOther Scientific based faithsAgnosticAtheistOther / NoneNot willing to disclose
In accordance with the Data Protection Act of 1998, all information provided on the referral form and in any further dealings with the Hammersmith and Fulham Employment and Wellbeing Services will be treated as confidential and will not be disclosed to any third party without express consent from the client.
However it is important that you understand that on occasions organisations are obliged to share certain information e.g. an individual is at risk to self or others, and may need to inform services such as Local Safeguarding of Vulnerable Adults Team; Child Protection Team; other staff; Service?s Regulator(s) and other agencies. Should this need arise the Service will make every effort to discuss this with you prior to any information being shared.
You should expect to hear from us within 3 working days of submitting your form.
If you?d like to speak to us about your application, please call us on 0330 008 3808 or email HFemploymentandwellbeing@richmondfellowship.org.uk.
