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Richmond Borough Mind

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Referral Form

*Please complete all mandatory fields

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First Name *

Date of birth:

Surname *

Contact Number:

Preferred Name *

Email Address: *

Can we leave voice messages?

Yes

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Address:

Emergency contact:

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

Name:

Number:

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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? *

Yes
No

Click to see what services are available for Adults or
click to see what services are available for Young People

Don’t know? click to see what services are available for Adults or click to see what services are available for Young People

Please select from the services listed below:

Adult Services

Psychotherapy and Counselling: work through your psychological difficulties with a therapeutic style to meet your needs. Not currently taking referrals for this service.
NHS Richmond Talking Therapies: Learn how to manage your thinking and improve how you are feeling with short term courses for low-mood and more.
Journey Recovery Hub: out of hours support for those in imminent mental health crisis, create a safety plan and prevent further escalation.
The Wellbeing Centre: move toward recovery of long term mental health problems through physical, educational and social activities.
Connect to Tech: learn how to use technology so it has a positive impact on your wellbeing through training, peer support and use of our ‘digital pod’
Peer Group Network: groups run by people who have experienced their own mental ill health. Benefit from support and enjoy a range activities.
Positive Living Group: take part in movement and relaxation, connect with others through therapeutic cooking. Learn how food impacts mental health and how to boost mood.
Mind n Mortlake: Benefit from ongoing 1-to-1 and peer support plus social activities and trips.
Befriending: work with a trained volunteer befriender who will support you over the phone weekly for 6-8 weeks.
Carers in Mind: one-to-one support, advice and training, support groups and social activities for those supporting someone else with their mental health.
Outreach: connecting with people at venues around the borough to ensure no one misses out on specialist support.

Children and Young People’s services

Youth Zone: a wellbeing drop-in service for 12 – 25 year olds who want to chat, chill, take part in groups and classes or get 1-to-1 support, information or advice.
Counselling: (from Autumn 2022).
Peer Mentoring: train in how to support others with their mental health, or work with a mentor to build your confidence and self esteem.
Reach: a 3 part workshop series in which we explore common mental health issues. We focus on Anger Awareness, Anxiety Management, and Low Mood and Self-esteem.

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Primary language:

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

Do you need an interpreter?

Yes
No

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

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How would you define your ethnicity?

Asian/Asian British
Mixed/multiple ethnic groups
African/African-Caribbean/Black British
White
Other Ethnic Background
Rather not say

Asian/Asian British

Bangladeshi
Chinese
Indian
Pakistani
Any other Asian background

Mixed/multiple ethnic groups

Asian and White
Black African and White
Black Caribbean and White
Any other Mixed/ multiple ethnic background

African/African-Caribbean/Black British

African
Caribbean
Any other African/African-Caribbean/Black British background

White

British
Gypsy, Roma or Traveller
Irish
Any other White background

Other Ethnic Background

Arab
Any other ethnic group

If other, please specify:

Religion and Belief

Please tick as appropriate

Buddhist
Christian
Hindu
Jewish
Muslim
Sikh
Other
No religion/belief
Rather not say

If other, please specify:

Gender

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How would you describe your gender identity?

Female
Male
In another way
Rather not say

If another way, please specify:

Does your gender differ from how it was assigned at birth?

Yes
No
Rather not say

Sexual Orientation

How would you describe your sexual orientation?

Asexual
Bisexual
Gay
Heterosexual / Straight
Lesbian
In another way
Rather not say

If another way, please specify:

Health Conditions and Disability

Do you identify as having any of the following? Please tick all that apply

Mental Health needs
Physical Heath needs
Additional Learning needs
Additional Hearing or Vision Needs
Accessibility needs
Neurodiversity needs
None
Rather not say

Employment

How would you describe your current situation?

Working full-time
Working part-time
Not working
Studying
Volunteering
Retired
Other
Rather not say

Other - please describe your current situation:

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.

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Donate e-news Self Referral Crisis Support

Home
About Us
Support Us
Adults
Young People
Carers
- Carers in Mind
- Peer Support for Carers
Training
Get Involved
Contact Us

Richmond Borough Mind

1st Floor Rear
UK House
82 Heath Road
Twickenham
TW1 4BW

020 8948 7652

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Contact Us

Richmond Borough Mind

1st Floor Rear
UK House
82 Heath Road
Twickenham
TW1 4BW

020 8948 7652

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