Referral Form

Referral date:

Professional referralSelf-referral

First Name

Middle Initial:

Surname:

Date of Birth:

Home address:

Postal Code:

Contact Details:Required

Mobile Number:Required

Email:Required

GP Details:

*Please tick your preferred means of contact

Name:

Agency:

Agency address:

Postal Code:

Contact Details:

Email:

Relationship to the referred:
GPCPNSocial WorkerFamily / FriendOther

Please give a brief description of mental health difficulties:

What support are you hoping to access from Llanelli Mind?:

Please indicate any other health/mobility issues we should be aware of:

Does the referred have any issues with anger?
YesNo

Please tell us about any violent confrontations in the last five years including any convictions in relation to this.

Please tell us about any suicidal behaviour including suicidal thoughts and if these are historical or present.

Please tell us about any self-harm including historical.

Please tell us about any substance misuse issues.

Please tell us about any sensory experiences including hearing voices, visions and hallucinations.

Do you look after anyone? Or does anyone look after you?
YesNo

Are you a Veteran?
YesNo

Please tell us about any other support the referred has in place including family support.

Is there a risk management plan in place?
YesNo

Is the risk management plan attached?
YesNo

Is the person being referred aware of this referral and in agreement?
YesNo

Please tell us where you heard about Llanelli Mind’s services:

I declare to the best of my knowledge the above information is correct.

Print Name:

Signature:

Date: