Online Referral

Please Confirm the Following:

You are NOT in crisis or requiring urgent help today (if you are, please visit our Urgent Help page).
You ARE aged 16 or over and ARE registered with a local GP in Teesside (if you are not, please contact your GP to arrange a consultation).

I confirm the above

Online Referral Form

Please note: What you share with us remains confidential within the service. The exceptions to this include if you mention any serious risk of harm towards yourself, towards others e.g. child protection or any serious criminal acts e.g. crimes police aren't aware of, including terrorism. As we are an NHS service, we keep details about you as your GP surgery does. These are stored on a secure patient record system.

Please tick to confirm you understand and agree to this

Your Details

Forename(s): Surname: Date of Birth: NHS Number:

Contact Details

Street address:

Please check if you consent to receiving information regarding your care by post

Landline: Mobile: Email:

Consent to leave messages?

Voicemail

Text

More About You

Ethnicity: Gender: Is English your first language? If no, what is your first language?

Please check if you require an interpreter

Are you NHS frontline staff working in a Teesside Hospital responding to COVID-19 cases? If you are a student, please state your college/sixth form: Are you a veteran? If yes, what is your service number? Please list the names and D.O.B of any children in your care (up to 18 years old): Are you or your partner pregnant? Any special requirements or long-term health conditions (i.e. ground floor room etc.)?

GP Details

GP Practice Registered GP

Current Prescribed Medication

Type

Dosage

Duration

Type

Dosage

Duration

Type

Dosage

Duration

Previous or Current Service Involvement

Please provide details (inc. Dates) of any other previous/current service involvement (e.g. Talking therapies, secondary services, social services, drug/alcohol services, etc.)

Reasons for Referral

Please tell us why you have contacted us for support

Next of Kin

Next of kin name: Next of kin telephone: Relationship to you: Next of kin street address:

Check if you consent to Impact contacting them if needed