Birmingham & Solihull Mental Health and wellbeing Hubs

Referral Form

Our service is eligible for individuals 18+, registered with a GP in Birmingham & Solihull who meet one of the following (Please tick as appropriate): *

Under the Care of a Community Mental Health Team

On the Serious Mental Illness register (SMI)

Long term mental health condition (12 Months +)

Contact Details

Full Name *

Date of Birth *

Rio Number (if known)

Address including postcode *

Contact Number *

E-mail Address

Location Preference

Our hubs are across Birmingham and Solihull, and a person can access all hubs once registered. However, as a primary location, which would be the preferred hub location?

Please state preference for location? *

Referrer’s Details (CMHT’s/GP/CPN/Other)

Name

Role

Contact Number

Email

Organisation

GP Details

GP Name *

Surgery Name / Address *

Contact Number *

Emergency Contact

Name of Emergency Contact

Relationship

Contact Number

Demographic Information & Equal Opportunities

Gender *

Ethnicity *

Sexuality *

Religion *

Please let us know whether there are any additional support required to access the service (Language needs, physical/learning disability, hearing or sensory needs, timing of appointments etc.)

Risk Information

We do require information regarding any risk around your health and wellbeing. We may contact a key mental health professional for this information but please supply as much information as you can below:

SELF-HARM / SUICIDE *

Yes

No

SELF-HARM / SUICIDE

Historical

Current

SELF-HARM / SUICIDE - Notes and details

SELF-NEGLECT *

Yes

No

SELF-NEGLECT

Historical

Current

SELF-NEGLECT - Notes and details

HARM TO OTHERS / FROM OTHERS *

Yes

No

HARM TO OTHERS / FROM OTHERS

Historical

Current

HARM TO OTHERS / FROM OTHERS - Notes and details

SUBSTANCE MISUSE *

Yes

No

SUBSTANCE MISUSE

Historical

Current

SUBSTANCE MISUSE - Notes and details

FORENSIC HISTORY *

Yes

No

FORENSIC HISTORY

Historical

Current

FORENSIC HISTORY - Notes and details

Mental Health Conditions

Mental Health Conditions: (Please tick all that apply) *

Mental Health Needs

Mental Health needs: Please provide a brief overview for reason for referral and presenting mental health need *

Additional Neurodivergent Needs

Additional Neurodivergent Needs: (Secondary to mental health diagnosis) *

Privacy, Consent & Information Sharing

We may collect further information from third parties, statutory and voluntary agencies who you have worked with you. We use your information to: Help meet your needs in the safest and most effective way and work effectively with other organisations involved in your care. We will always ask for your consent before sharing in this way. Sharing of information between Birmingham Mind & Creative Support may take place to ensure our service can meet your needs. We may share anonymised data with the people that fund our services. All your information is held securely and is only accessible by those who have permission to see it. You have the right to: be informed of your rights and how your data is used, request access to a copy of your information, have your information corrected or updated and remove your consent at any time.

Please confirm below that consent is given or has been sought and gained, for the following:

The person being referred has consented to this referral: *

Yes

No

The person being referred has consented to sharing their information: *

Yes

No

Your Full Name *

Signature *

clear

Date +

Anxiety	Bi-polar	Depression	OCD
Personality Disorder	Psychosis/Schizophrenia	Eating Disorder	PTSD
None disclosed	Other