Mental Health Link: Adult Early Support Referrals

Referrer

First Name

Last Name

Referring Organisation

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 person your are referring, 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 this person aware that a referral is being made on their behalf, and that their details are being shared with Manchester Mind?

Yes

We will use the details in this form to contact this person and arrange an assessment meeting with them. Please make sure they are aware this will happen before proceeding with this referral.

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

Person Being Referred

First Name

Last Name

LAS ID

Address Line 1

Address Line 2

Address Line 3

Town/ City

Postal Code

Please leave at least one phone number or email address we will use these to contact the person about their referral.

Mobile

Phone

Contact Preference Notes

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

Personal Details

Birth Date

How do they describe their gender?

Female

Male

Non-binary

Another/ prefer to self-describe

Prefer not to say

Other gender

Referral Details

Reason For Referral