Manchester Mind Counselling Referral Form (Manchester University Students Union)

Referrer

First Name

Last Name

Phone Number

Your Contact Details

Your contact details will be held on Manchester Mind's database, which can only be accessed by current Manchester Mind staff.. We will not share these with any other organisation. We will use these details if there is an issue with the referral (e.g. we cannot make contact with the young person, or we need further details about their situation), a member of Manchester Mind staff may contact you for more information. For more details of how we hold personal data please see our Data Privacy Notice.

Is the young person aware that a referral is being made on their behalf, and that their details are being shared with Manchester Mind's Children and Young People's Service?

Yes

Please make sure the Young Person is aware Manchester Mind will be in contact with then before continuing with this referral.

Student Details

First Name

Last Name

Their preferred pronouns (if known)

Address Line 1

Address Line 2

Address Line 3

Town/ City

Postal Code

Country

Please leave at least one phone number or email address for the young person. This will be used to contact them about their referral.

Mobile

Phone

Preferred Communication Method(s)

Phone

SMS

Contact Preference Notes

Any information about how and when this young person prefers to be contacted. The best timeand method to contact them. Is it ok to leave a voice message or send an SMS.

Birth Date

Referral Details

What would you like Manchester Mind to help you with?

What is the young person's situation? What would you like Manchester Mind to help with?

Preferred Language

Interpreter needed?

Yes

Most of our services are conducted in English. We are able to offer some of our services in Hindi, Urdu, and Punjabi. For other languages we use the help of an interpreter where we can. Please let us know if you would like to explore this option.

Risk Outline

Is the young person a risk to themselves or others?

Yes

Don't know

Please give a brief overview of any risks Manchester Mind may need to be aware of

Do you get any support from other agencies?

Yes

Additional agencies support information

GP, Psychiatrist, CPN- Community Psychiatric Nurse, Social Worker etc