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Charity No. 1003061 0300 111 6000 [email protected]

Suffolk Mind Connect referral form - Emotional Wellbeing Hub

Fields marked with an * are required

Emotional Wellbeing Hub Manager

Date of discharge *

Referrer's name *

Referrer's email address*

Has the client agreed to transfer to Connect?*YesNo

Has the client been informed of transfer both verbally and in writing?*YesNo

Client information

RMY number

NHS number*

First name*

Last name*

Full address*

Postcode*

Date of birth *

Mobile Number*

Landline number

Email address

GP Surgery*

Background information

Reason client was referred to EWH, and what support can Suffolk Mind Connect provide?*

Are there any other organisations involved in this client’s care?

What is the clients mental health diagnosis?*

Can you provide any background information on this client?*

Is the client any risk to self? Please provide any current or historical self-harm, suicidal ideation and/or suicide attempts?*

Current medication*

What best describes their gender identity?*

Is their gender identity the same as the sex they were assigned at birth?*

Sexual Orientation*

Ethnicity*

Nationality *

Religion*

Employment status*

Do they have an activity limiting disability under the Equality & Diversity Act 2010?*

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 about the client is accurate to the best of my knowledge.

The client authorizes Suffolk Mind to store personal information related to them and the service they receive.

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

I am happy to accept the above terms and conditions.