How to Refer

Patient/Client’s Name*

Date of Birth*

NHS Number*

Gender*

Female
Male
Prefers not to say

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Prefers to self-describe as:

Patient/Client’s Contact Details:

Address*

Address 1 Address 2 Town Postcode

Contact Phone Number*

Contact Email*

Preferred method of contact?*

Phone
Email
SMS

Is it safe/appropriate for us to leave a voicemail message?*

Yes
No - if no answer please call back another time

Name and role of person requesting the contact:*

Email of person requesting the contact*

Is the patient/client a carer for another individual receiving services? (mental or physical health)*

Yes
No

Patient/client’s emergency contact details (if available):

Patient/client’s GP details:*

Further information

Current presenting difficulties?*

Please give as much information as possible in the text box below. E.g. suicidal thoughts, self-harming, eating disorder, mental or physical wellbeing, loneliness, isolation, housing or debt advice needed, etc. This will help us to direct the patient/client to the most appropriate service.

Please give details of current and historic risk information relevant to the support needed:*

What specific needs has the patient/client expressed or requested in terms of support?*

E.g. 1-1 support, group sessions, housing advice, financial advice, help with goals, etc.

Are there any barriers to support?*

E.g. disability, neurodiversity, isolation, transport, etc.

Has the patient/client indicated any interests or hobbies?*

If so, please give details. This will enable us to identify groups and activities that will reduce isolation and loneliness.

Will the patient/client continue to receive support from your service?*

Yes
No

If Yes, please give details below

(type of support, name and contact details for supporting service).

Has the patient/client consented to their information being shared?*

NB. Information will only be shared within the OMH Alliance. We will not share the patient/client’s information with any other services without their express permission unless there is a concern for their or someone else’s safety and the information is relevant.

Yes
No

Where in Somerset is the patient/client based?*

We use what we call a locality model at Open Mental Health. This means that a patient/client will be referred to one of our four locality hubs across Somerset. Within these hubs sits a team of professionals who together will discuss which Open Mental Health services are best placed to support the person.

Mendip
Sedgemoor
South Somerset
Taunton & West Somerset

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Phone

This field is for validation purposes and should be left unchanged.

Professional Referral Form

Patient/Client’s Contact Details:

Further information

Phone referrals

Direct contact

A New Group to Support Unpaid Carers