Confidential Referral Form

Are you completing this form for yourself or someone else?*

It's for me It's for someone else

If you are completing this form on behalf of someone else, please enter your name, contact number/email and relationship to them in this box

Does the person know you have made a referral to Doncaster Mind?*

*Please select Yes No

Name*

Address*

Postcode*

Date of birth*

Gender*

*Please select Female Male Non-Binary Trans male Trans female Prefer not to say Other

Home phone

Mobile*

Email

How can we contact you?*

*Please select Phone Email Post

What service(s) are you interested in accessing at Doncaster Mind?*

*Please select Mentoring Guided Learning Wellbeing Sessions/Activities Thrive@DM Keeping Families in Mind Counselling Bereaved by Suicide

Do you have a family member who is currently serving in the armed forces; or a veteran of the armed forces?*

*Please select Yes No Unknown

Are you (or the person you are referring) in regular contact with your (or their) GP, A&E, 111, Crisis, emergency services or others for help and support with emotional and mental wellbeing?*

*Please select Yes No

Please tell us about your mental health and how we might help you:*

Do you currently have any other support (family/friends/professionals)?*

How did you hear about the service?*

Any additional information you would like us to know