Professional referral - Telford Stars

Has the client consented to this referral?*

Yes
No

Consent to contact by: Telephone/Mobile*

Yes
No

Consent to contact by letter:*

Yes
No

Can we say who we are by text or voice message:*

Yes
No

Consent to be contacted by a volunteer:*

Yes
No

Any disability requirements?*

Yes
No

Any literacy difficulties?*

Yes
No

Interpreter required?*

Yes
No

Referrer’s details

Your name (referrer):*

Your organisation:*

Job title:*

Contact number:*

Email address:*

Enter Email Confirm Email

Service user’s details

Forename:*

Surname:*

Gender:*

Male
Female

Date of birth:*

Address:

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

NOTE: If NFA, ask ‘Are you in receipt of Benefits?’ If Yes, use address which they claim from.

Home number:

Mobile Number

Email address:

Enter Email Confirm Email

Consent to contact GP:*

Yes
No

GP Surgery address:*

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

Next of kin details

Name:*

Relation to client:*

Contact number:*

Service user's assessment

Alcohol use:*

Yes
No

Specify how much and how often:*

Please tick areas of concern:*

Physical health
Emotional health
Family
Relationships
Housing
Work
Employment
Finances
Illegal activities

Drug use:*

Yes
No

Specify how much and how often:*

Please tick areas of concern:*

Physical health
Emotional health
Family
Relationships
Housing
Work
Employment
Finances
Illegal activities

Is client or partner pregnant:*

Yes
No

Due date:*

Current/history of mental health, and self-harm or suicidal thoughts/plans: Please specify*

Does client need to be seen by a male or female worker? Please specify*

Other service involvement (Social Care, probation, CMHT, Health Visitor): Please specify*

Criminal Justice (current or past cautions): Please specify*

Any children which may be in need/Risk: Please specify*

Physical health conditions or symptoms which are likely to require treatment: Please specify*

Client may present harm to self or others (threatening behaviour, verbal aggression, physical aggression): Please specify*

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.
Once submitted Inclusion will use this information to contact the individual you have referred, we will keep information in line with MPFT data protection policy. Please refer to your organisations data protection policies when sending the referral.

What help can we offer?

Professional referral form

Referrer’s details

Service user’s details

Next of kin details

Service user's assessment