Tesco Teddington Big Brunch

Referral Form

*Please complete all mandatory fields to access our free services.

For our Counselling and Psychotherapy service please email: counselling.admin@rbmind.org

For NHS Richmond Talking Therapies please visit: https://tinyurl.com/3rmjhdn5

First Name

Date of birth:

Surname

Contact Number:

Preferred Name

Email Address:

Can we leave voice messages?

Address:

Emergency contact:

Someone who can be contacted on your behalf in an emergency if you wish

Name:

Number:

Reason you are seeking support:

Please tell us about our current situation and mental health concerns.

Relevant medical history:

Please tell us about any other times you have experienced mental health issues, any self-harm, suicidal thoughts or attempts

Do you know which service(s) you are interested in?

Click to see what services are available for Adults

For our Counselling and Psychotherapy service please email: counselling.admin@rbmind.org

For NHS Richmond Talking Therapies please visit: https://tinyurl.com/3rmjhdn5

Primary language:

Any special requirements e.g. adjustments to accommodate a disability:

Do you need an interpreter?

Equalities monitoring questions are anonymised and analysed statistically to help us and our funders understand the extent to which our clients represent the local community we serve.

Ethnic Origin

Religion and Belief

Gender

Sexual Orientation

Health Conditions and Disability

Employment

Financial Situation

Which of these statements best describes your current situation?

I/We feel like we have enough income to support ourselves financially and live a good standard of living.
I/We get by day-to-day but are under pressure. It is difficult to manage unexpected costs and events.
I/We are falling short of a decent standard of living.
I/We can’t afford to eat, keep clean and stay warm and dry.
Rather not say

Any personal information you share with Richmond Borough Mind will be kept secure and used in line with the General Data Protection Regulation 2018 (GDPR). We may also make contact with other people supporting your mental health to discuss your referral. This information will only be used to assess your needs and the services that you may benefit from. Information about you will be kept confidential and will not be disclosed to third parties without your prior consent except where required by law, or where we are concerned about your safety or the safety of others. You can withdraw or change your agreement for Richmond Borough Mind to hold or process your personal information at any time.

I agree to monitoring information being held by Richmond Borough Mind and stored on their database
I understand that the following information may be shared with my GP, my care team or emergency services if there is a concern over my wellbeing or safety; or risk to myself or others

The information that we keep is used to ensure that we can:

contact you
make informed decisions about services and support you need
manage risks to your own wellbeing, and others’ wellbeing
review services to ensure they are effective
monitor numbers of people receiving a service
show what the funding was used for

Protection Regulation 2018 (GDPR) and our Privacy Policy.

Please tick this box if you would like to receive our monthly e-newsletter ‘Mindful Memo’ and occasional emails about our work and events. You can unsubscribe at any time.

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