Professional Referral Form

Health Care Professional eReferral

Please note: this service is not suitable if the person you are referring is at immediate or imminent risk to themselves or others. Please see this page to see how they can access support:

To help us to put them in touch with our team, please complete the form below.

If they want to find out more about how we use their information please see this page to see our terms and conditions:

Designs in Mind is contracted by NHS Shropshire, Telford and Wrekin. To access our service you need to be registered with a Shropshire, Telford and Wrekin GP. If your GP is located in a different area, you can click here to find the contact details of the IAPT service linked to your GP surgery:

Please note, that we require consent from the client to process the referral, if the client has not permitted you to submit this referral, do not submit it.

Professional Referral Form

Client/Patient contact information

Please fill out your clients personal details so we can process your referral.

NHS Number

Title

First Name

Last Name

Phone/Mobile

Address Line 1

Address Line 2

Town/City

Post Code

Does the client provide consent for us to send correspondence to this address?

Yes

Date of birth

Gender Identity

Is your clients gender the same as assigned at birth?

GP Surgery

Marital Status

How would you describe your clients ethnic origin?

If other please state

Religion

Receive Confirmation

I would like to receive a confirmation of my self referral to the email address I specified above. Please check the spam folders within your email if you do not receive a confirmation in your inbox.

Terms

Does the client accept the terms and conditions?

Health & Disabilities

Please give us information about your health and disabilities.

Does your client have any disabilities we should be aware of?

Please give further details of disabilities

Does your client have any long term health conditions?

Please give further details about their long term health conditions

Please a brief description of the mental health difficulties your client is experiencing?

Next of Kin

Please give us details about your clients next of kin.

Full Name

Relationship to yourself

Address Line 1

Address Line 2

City/Town

Post Code

Next of kin email address

Phone for next of kin

Referrer Details

Referrer

Referrer Full Name

Agency Name

Referrer Address

Referrer Address Line 1

Referrer Address Line 2

Referrer City

Referrer Post Code

Referrer Telephone

Referrer Email

I confirm the person I am referring gives permission for you to discuss details of their referral with me

Yes

Please provide a brief summary of clients problem

Additional Information

Please detail any known risk (current or historic), or confirmation of no known risk.

Does the client have any disabilities we should be aware of?

Does the client have any long-term health conditions?

Does the client provide consent for us to share your referral?

Yes

Terms & Consent

For us to process your clients referral, please read and agree to our terms.

How did you hear about our service?