Humankind

Name

First

Last

Date of birth

Gender (at birth)

Male
Female
Prefer not to say

Do you identify as the gender you were assigned at birth?

Yes
No
Prefer not to say

NHS Number

Do you have a fixed abode/address?

Yes
No

Address

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Phone number

Email

Preferred contact methods

Please specify your preferred contact method

If you selected "Other", please provide your preferred contact method in the box above.

Are you making this referral for yourself or someone else?

Myself
Someone else

Is the person you are referring aware of this referral?

Yes
No

Referrer name

First

Last

Referrer organisation

Referrer email

Referrer phone number

Do you or the person you are referring have any communication or information needs?

Give details any any communication/information needs such as interpreter required, large print letters, BSL, induction loop, etc. in the box above.

We are required to ask you some sensitive questions in order to process your referral for our support. Are you happy to proceed with these questions?

Yes
No

What is your/the person you are referring's employment status?

Emlployed
Unemployed

Area of employment

Add occupation in the box above.

What are your/the person you are referring's working hours?

Add working hours in the box above.

Do you have any additional mental or physical health issues?

Yes
No

Are you/the person you are referring currently using any substances?

Yes
No

What was the date you/they last used?

Are you pregnant

Yes
No

Are you the partner of someone who is pregnant?

Yes
No

Are you a carer for someone else?

Yes
No

Do you have regular contact with under 18s?

Yes
No

This can include people who live with you or may visit/you may visit.

Reason for referral and goals for treatment.

Provide reasons for referral and any goals from treatment in the box.