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Referral Form

Fill in our form to get the help you need or to support your client. Before you continue, please note that we do not offer crisis support. If you are in a crisis that puts your safety at risk, please visit our emergency contacts page to learn how to get the help you need.

Are you over the age of 18?(Required)

Yes

Suffolk Mind currently only offers services to people who are aged 18 or over, so we cannot take a referral at this time. However, please take a look at our Children and Young People Signposting guide for information about support for under 18s.

Do you live in Suffolk (excl. Waveney District)?(Required)

Yes

(Click here to check if you’re within the Waveney District)

At this time, Suffolk Mind only provides services to Suffolk, except for Waveney. Please find your local Mind who will be able to support you, or contact our team on 0300 111 6000.

Services – please choose which service(s) you require:(Required)

Counselling

Suffolk Work Well (Employment Support)

Cognitive Behavioural Therapy (CBT)

Suffolk Night Owls

Eating Recovery

Anxiety Management Course

Frontline Partners

EMDR

GreenCare

Menopause and Me

Gambling Harms

Are you experiencing the perimenopause/menopause?(Required)

Yes

Are you:(Required)

A partner of a service person

I am interested in:(Required)

Community Outreach

Counselling

Suffolk Work Well employment support

Which GreenCare allotment would you like to join?(Required)

Ipswich

Bury St Edmunds

Haverhill

Felixstowe

Have you previously accessed Suffolk Work Well?(Required)

Yes

When did you last access Suffolk Work Well?(Required)

Please enter the month and year

Are you currently employed?(Required)

Yes

Do you consider yourself to have been bullied by a colleague or manager?(Required)

Yes

Has this affected your mental wellbeing?(Required)

Yes

Have you been subject to any discrimination?(Required)

Yes

Has this affected your mental wellbeing?(Required)

Yes

Please check the list below to see if you may be eligible for any of our grant-funded (free) Anxiety Management courses(Required)

Please check the list below to see if you are eligible for any of our grant-funded (free) Menopause & Me(Required)

We don’t currently have any other dates available for Anxiety Management. Please continue with this referral if you’d like to be added to our waiting list.

Please check the list below to see if you may be eligible for any of our grant-funded (free) counselling sessions(Required)

Is your counselling being funded by a third party?(Required)

Yes

Is your CBT being funded by a third party?(Required)

Yes

Is your EMDR being funded by a third party?(Required)

Yes

Details of funder(Required)

(organisation, contact name, address and code if required)

Number of sessions being funded (£58 per session):(Required)

This field is hidden when viewing the form

How has the Sizewell C development impacted you and/or your community?(Required)

Our counselling is a fee paying service, do you wish to continue with this referral?(Required)

Yes

CBT is a fee paying service, do you wish to continue with this referral?(Required)

Yes

EMDR is a fee paying service, do you wish to continue with this referral?(Required)

Yes

Please choose one:(Required)

Which counselling location would you prefer?(Required)

Telephone

Face to Face Bury St Edmunds

Face to Face Ipswich

Saxmundham (Thursday only)

Haverhill (Tuesday daytime only)

Zoom

Which counselling location would you prefer?(Required)

Telephone

Face to Face Bury St Edmunds

Face to Face Ipswich

Saxmundham (Thursday only)

Haverhill (Tuesday daytime only)

Zoom

Which counselling location would you prefer?(Required)

Face to Face Bury St Edmunds

Face to Face Ipswich

Saxmundham (Thursday only)

Haverhill (Tuesday daytime only)

Zoom

Which counselling location would you prefer?(Required)

Face to Face Bury St Edmunds

Face to Face Ipswich

Saxmundham (Thursday only)

Haverhill (Tuesday daytime only)

Zoom

How can we help with Gambling Harms? Please tick all that apply.

Counselling for those affected by gambling harms

Understanding & Supporting Addictive Behaviour workshop – gambling harms

Anxiety Management workshop – gambling harms

Which counselling location would you prefer?(Required)

Face to Face Bury St Edmunds

Face to Face Ipswich

Saxmundham (Thursday only)

Haverhill (Tuesday daytime only)

Zoom

Which CBT option would you prefer?(Required)

Face to Face Ipswich

Face to Face Bury St Edmunds

Zoom

Which CBT option would you prefer?(Required)

Face to Face Ipswich

Face to Face Bury St Edmunds

Zoom

Which CBT option would you prefer?(Required)

Face to Face Ipswich

Face to Face Bury St Edmunds

Zoom

Which CBT option would you prefer?(Required)

Face to Face Ipswich

Face to Face Bury St Edmunds

Zoom

Which EMDR option would you prefer?(Required)

Face to Face Bury St Edmunds (Tuesdays)

Online/Virtual

For CBT, we ask that you have at least one of the following. Please tick one or all that may apply:(Required)

Depression

Specific Phobias

Panic Disorder

Social Anxiety Disorder

Obsessive Compulsive Disorder

Health Anxiety

Post Traumatic Stress Disorder

Other

Depending on the presentation, our CBT therapists may offer up to 23 sessions and some sessions may be 90mins in length.

If other, please give further details below(Required)

Which Waves location would you prefer? (please tick a maximum of two)(Required)

Online/virtual

Bury St Edmunds

Felixstowe

Haverhill

Ipswich

Do you have an official diagnosis of disordered eating?(Required)

Yes

Which eating patterns best describe your disordered eating?(Required)

Anorexia

Bulimia

Binge Eating Disorder

Other

If other, please give further details below(Required)

Which Eating Recovery location would you prefer?(Required)

Online/virtual

Bury St Edmunds

Ipswich

For NHS counselling support, please visit the Suffolk Wellbeing service website. You can also self-refer to one of our other services.

For NHS CBT support, please visit the Suffolk Wellbeing service website. You can also self-refer to one of our other services.

Please note: if you are referring for both our Waves and Eating Recovery services, we are unable to refer you to both at the same time.

You will not be able to attend Waves until 8 months after you have completed Eating Recovery, and vice versa.

What is your NHS number?(Required)

Are you a professional completing this referral on behalf of someone ?(Required)

Yes

Are you a professional completing this referral on behalf of someone?(Required)

Long Covid support (SNELCAS)

Are you registered with SNELCAS?(Required)

Yes

Please contact SNELCAS first before completing this self-referral form

Please select the Long COVID support you’d prefer(Required)

Long COVID, Sleep & Mental Wellbeing Course (4 week online course)

CBT Counselling

Please note that all courses take place virtually.

Your professional details

Your name(Required)

Your organisation(Required)

Your email address(Required)

Your contact number(Required)

Your client's NHS number(Required)

Is client aware that you are completing this referral form on their behalf?(Required)

Yes

Your personal details

Your client’s details

First Name(Required)

Last Name(Required)

Email(Required)

Phone Number(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Postcode(Required)

Select address

Address (Line 1)(Required)

Address (Line 2)

Town/City(Required)

Accommodation Status

GP Surgery Name(Required)

(We only contact your GP surgery in case of an emergency when accessing our service. If your GP is not listed, please contact us on 0300 111 6000)

If you can't find your GP on this list, please let us know below.(Required)

How did you hear about this service?

Referral details

Do you have a mental health diagnosis (official or unofficial)?(Required)

Yes

If yes, please list:(Required)

Reason for your referral(Required)

Please do provide as much information as you can, as this will enable the service to support you in the best way possible.

Are you being prescribed any medication?(Required)

Yes

If yes, please list your medication(s)(Required)

Please tick if you have any of the following:

This will help us to ensure we give you the right support

Diabetes

Epilepsy

Hearing impairment

Neurodiversity

Other

Physical impairment

Sight impairment

Do you have Type 1 or Type 2 diabetes?(Required)

Type 1

Type 2

Please tell us about your epilepsy(Required)

Please tell us about your hearing impairment(Required)

Please tell us about your neurodiversity(Required)

Please let us know what support you need(Required)

Please tell us about your physical impairment(Required)

Please tell us about your sight impairment(Required)

Do you currently self-harm or have suicidal thoughts?(Required)

Yes

No, but I have in the past

Trigger

If you or someone you know is currently in crisis, please call 999 or visit A&E. You can also visit our Understanding self-harm and suicide page for more information.

Can you tell us a bit more about your self-harming or suicidal thoughts?(Required)

Can you tell us a bit more about when you last self-harmed or had suicidal thoughts?(Required)

Do you currently receive support from any other organisation (including mental health)?(Required)

Yes

Please tell us which organisation(Required)

Equality & Diversity details (optional)

What best describes your gender identity?

Is your gender identity the same as the sex you were assigned at birth?

Sexual Orientation

Ethnicity

Nationality

Religion

Employment Status

Employment sector/type

Do you consider yourself to have an activity limiting disability under the Equality Act 2010?*

Communications

Please note, we will contact you via email to acknowledge receipt of your referral form

The individual service will need to contact you to discuss your referral, please select your preferred method of contact:(Required)

Telephone

I declare that the information provided by me is accurate to the best of my knowledge.(Required)

By submitting this form, I give permission for Suffolk Mind to process my personal data inline with their Privacy Policy.

Referral Form

Long Covid support (SNELCAS)

Your professional details

Your personal details

Your client’s details

Referral details

Equality & Diversity details (optional)

Communications

Accreditations & Awards