Referrer details Referrer Name
Relationship to client
Professional Organisation (if applicable)
Contact Telephone Number
Email Address
Client details Name
Date of Birth
Age
Gender
Preferred pronouns
Address
Preferred contact method (if under 18 the referrer will be contacted)
Reason for referral - please tick all that apply Self harmSuicidal thoughtsSuicide attemptEmotional or psychological distressOther (please specify)
Other:
How long have they been feeling this way?
Have they felt this way or similar previously? Please provide details and any diagnosis or treatment/support received:
Are they experiencing any of the following symptoms (tick or describe as appropriate) AnxietyPanic symptomsLow confidence/self esteemEmotional regulation difficultiesOther (please specify)
Other or further details:
Background information Include any relevant history such as family context, education, work, housing, significant life events, or previous support:
Current Support Are they currently receiving any support from other services or on a waiting list? If yes please provide details of services, named workers and contact information if known:
Risk and safeguarding information Please indicate any known risk to self or others, safeguarding concerns or relevant behavioural information: No known risksSelf-harmSuicidal thoughtsAggression towards othersOther please specify
Medical Information Any diagnosed conditions (e.g. anxiety disorders, ASD, ADHD)
Medication (if applicable)
Allergies or health condition
As the referrer I consent to this information being shared with professionals within Humber Wellbeing Services and to be contacted as appropriate.
Has the client consented to this referral?
info@humberwellbeinghub.com
Humber Wellbeing Hub, Country Park, Humber Bridge, Hessle, HU13 0LN
