Referral Form


    You must 18 years of age or over in order to complete this form.

    Fields marked with an * are required

    Please note, due the current situation regarding COVID-19, there may be a longer waiting list for some services. We will of course try to ensure your needs are met during this time but please bear with us. Sorry for any inconvenience caused and thank you for your understanding.

    If you are experiencing any problems completing this form or would like help to do this, please call 0300 111 6000.


    Are you over the age of 18?*

    Services - please choose which service(s) you require:*

    Counselling Locations*

    GreenCare Locations*

    Waves Locations*

    Suffolk Work Well locations - we are currently operating our Suffolk Work Well service remotely, however we can provide face-to-face support depending on circumstances.*

    CBT Locations*

    Suffolk Mind currently only offers services to over 18yrs old so we can not accept your referral at this time. However there are many services who can support you, contact information as well as advice and guidance can be found here

    Our service is a fee paying service, do you wish to continue with this referral?:*

    Please choose one:*

    The NHS counselling service is provided by Suffolk Wellbeing Service

    Is your counselling being funded by a third party? *

    Details of funder (organisation, contact name, address and code if required)

    How did you hear about this service?*

    Are you a professional completing this referral on behalf of someone?*

    Name of professional*

    Organisation*

    Contact email address*

    Contact number*

    Is client aware that you are completing this referral form on their behalf?*

    Phone*

    Email *

    Full Postal Address*

    Postcode*

    GP surgery (We only contact your GP surgery in case of an emergency when accessing our service)

    Mental health diagnosis and/or reason for referral*

    Please list any medication you may be taking for your mental health:

    Do you currently self-harm or have suicidal thoughts?*

    Are you under a mental health team? *

    Please state which mental health team:*

    Can you please explain in more depth about this and how to manage this?*

    What do you hope to gain from therapy?*

    For CBT, we ask that you have a minimum of three different presentations.

    Depending on the presentation, our CBT therapists may offer up to 20 sessions and some sessions may be 90mins in length.

    Please select from the list below:*

    Background information - tell us about yourself. What do you like? What don't you like? Do you have any pets? Etc. Our Suffolk Night Owls team can refer to this information when talking to you. *

    What support would you require if you called Suffolk Night Owls? We understand that this can be hard to answer if you haven't called SNO yet, but we would like to know how best to support you if you called us in distress. What would you like us to talk to you about? Or NOT talk to you about? *

    Are you in contact with any other organisation, i.e. support workers, housing association, Citizens Advice? If yes, please list. If not, please put N/A. *

    If you have self-harmed before calling us, and inform us on the call - how would you like us to respond? For example would you like us to call a next of kin on your behalf, encourage you to call 111 or seek further medical advice? *

    Do you use any other Suffolk Mind service? If yes, please state which service. *

    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 (if applicable)

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

    We communicate with our clients by email, telephone, text and letter (which will be sent to the address supplied on this referral form). “I am happy for Suffolk Mind to communicate with in the following ways"*

    Are you happy for other services within Suffolk Mind with whom you are registered to exchange relevant wellbeing information?*

    Confidentiality & Data Protection

    Suffolk Mind is committed to maintaining client confidentiality. All information about you is held securely. We will never sell or share your personal information except with trusted partners and suppliers who work with us on or on our behalf to deliver our services. You have the right to request access to a copy of the personal information that we hold about you.

    For further information please view our Privacy Policy


    Declaration

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

    If I choose to go ahead with my referral through this service, I hereby authorise Suffolk Mind to store personal information related to me and the service I receive.

    If you are happy to accept the above terms and conditions please tick the following box and click on the button marked submit.