Online referral - Telford Stars

First name*

Last name*

Gender*

Please select

Date of Birth*

Address*

If you don't have a fixed address (NFA) and are receiving benefits please use the address used for your claim

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Are you registered with a GP/Doctor*

Yes
No

GP Address*

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Contact number*

Email address*

Can we contact you by telephone/mobile?*

Yes
No

Can we say who we are by text or verbal message?*

Yes
No

Can we contact you by letter?*

Yes
No

Our service has trained volunteers, can a volunteer contact you?*

Yes
No

Do you have any disabilities?*

Yes
No

Do you have any literacy difficulties?*

Yes
No

Do you need an Interpreter?*

Yes
No

Do you drink alcohol?*

Yes
No

Specify how much and often*

Does your alcohol use cause you any concerns with your...*

Physical Health
Emotional Health
Family
Relationships
Housing
Work
Employment
Finances
Illegal Activities

Do you use drugs?*

Yes
No

Specify how much and often*

Does your drug use cause you any concerns with your...*

Physical Health
Emotional Health
Family
Relationships
Housing
Work
Employment
Finances
Illegal Activities

The following questions give us the information we need to prioritise your referral.

Are you or your partner pregnant?*

Do you have any current or previous mental health concerns?*

Do you have involvement with other services? For e.g. Social Care, probation, CMHT, Health Visitor Please specify*

Do you have any physical health conditions or symptoms which are likely to require treatment? Please specify*

Do you want to tell us anything else?*

Pressing send on this form means you are giving your permission for Inclusion to store the information you have provided and contact you in-line with Data Protection legislation. We will contact you on the phone number or email provided so we can determine how we can best support you in our service.

Well done for taking the first step!

Are you a professional wanting to refer someone? Please click here

Referral form

The following questions give us the information we need to prioritise your referral.