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 personal information? *

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

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

If you are under the age of 14: Has your Parent/Carer/Guardian been made aware that you are referring yourself to Roshni Ghar? *

Yes No Not Applicable

Section 1: Client Details

First Name *

Last Name *

Date of Birth *

Post Code*

Locality

Phone number *

Email Address

Preferred Language *

Other Language

Preferred communication method *

Section 3: 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 6: Monitoring Information

Ethnicity

Disability Impacting daily life?

Yes No Not Disclosed

Marital Status

Gender *

Sexuality

Religion

Other Religion

Roshni Ghar Self 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.

Consent to share with other Organisations

Section 1: Client Details

Section 2: Referral Information

Section 3: Medical / Clinical details

Section 4: Dependants / Carers

Section 5: Additional Information

Section 6: Monitoring Information