MYMUP

An asterisk (*) indicates an essential piece of information in the form below. Please complete these and as many other sections as you can. Thank you

Consent to share with other Organisations

Do you consent for Roshni Ghar to access and share your client's personal information? *

Yes - I give consent to Roshni Ghar to access and share personal information with other relevant service providers for the purposes of helping the client with their mental health and wellbeing needs

No - I do not give consent to Roshni Ghar to access and share personal information with other relevant service providers for the purposes of helping the client with their mental health and wellbeing needs

Is the client aware you are making this referral? *

Yes - I/the individual described here has given consent to Roshni Ghar to record sensitive personal information

No - I/the individual described here has NOT given consent to Roshni Ghar to record sensitive personal information

Section 1: Client Details

First Name *

Last Name *

Date of Birth *

Post Code*

Locality

Phone number *

Email Address

Preferred Language *

Other Language

Can Roshni Ghar contact the client directly? *

Yes No

Preferred communication method *

Section 2: Referral Information

Reason for referral

Is there a recent risk assessment?

Yes No

Does client have a Care Programme Approach plan?

Yes No Unknown

Name and role of other professionals involved

Section 3: Referrer details

First Name *

Last Name *

Job Title

Organisation Name

Phone number *

Email Address *

Source of referral

Other Referral Source

Section 4: Medical / Clinical details

GP name / Practice / Medical centre *

Relevant Medication

Diagnosis *

Other Diagnosis

Summary of mental health diagnosis / history *

(please write not applicable if no diagnosis history)

Section 7: Monitoring Information

Ethnicity

Disability Impacting daily life?

Yes No Not Disclosed

Marital Status

Gender *

Sexuality

Religion

Other Religion

Roshni Ghar Professional Referral Form

Please note that Roshni Ghar is a support service. If you are in crisis please:

Details of the Roshni Ghar Data Protection Policy can be found here: Data Protection Policy

Our data protection policy provides more details about how we store the information that you share with us on your behalf.