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Are you completing this form for yourself (self-referral) or on behalf of someone else?
*
Self Referral
On behalf of someone else
Referrer Organisation
Referrer Name and Relationship to the person being referred
*
Referrer Telephone Number
*
Referrer Email
Is the person aware that you are making a referral to the service and have they given CONSENT for you to refer on their behalf?
Yes
No (if you do not have consent, please speak to the person to obtain consent first)
Other
If other - please comment here
Name
*
First
Last
*** This is for the person who will be receiving the Listen and Connect service ***
Best Contact Number
*
Second Contact Number
Email
Home Postcode
*
Gender
*
Male
Female
Transgender
Non-Binary
Unsure
Prefer Not To Say
Age
*
18-24
25-34
35-44
45-54
55-64
65-74
75-84
85+
Employment Status
*
In Employment - Full Time
In Employment - Part Time
Unemployed
Student
Other
Main Language Spoken
*
English
Arabic
Bengali
Chinese - Cantonese
Chinese - Mandarin
Pakistani Pahari
Panjabi
Pashto
Polish
Somali
Urdu
Other
Ethnic Background
*
Asian - British Asian
Asian - Bangladeshi
Asian - Indian Other or Indian Sikh
Asian - Pakistani
Asian - Other Background
Black - African
Black - Black British
Black - Caribbean
Black - Other Black Background
Mixed / Multiple Ethnic Groups
White - English/ Welsh/ Scottish/ Northern Irish/ British
White - Polish
White - Other White Background
Other Ethnic Background
Prefer Not To Say
Have you (or the person you are referring) used this Listen and Connect service before?
*
Yes
No
Don't Know
What kind of support do you (or the person you are referring) need?
*
Meaningful Conversation
Explore Social Activities
Physical Activities e.g. cycling, walking & community activities
Information or Signposting to Housing/ Money/ Debt
Anxiety, Panic Attacks, Depression
Suicidal Thoughts/Intentions
Advice about COVID-19
Loneliness/ Isolation
Listen and Lunch (lunch club)
Talking Art
Other
If other - please comment here
Do you (or the person you are referring) currently receive support from any of the following;
*
Social Worker
Support Worker
Counsellor
Psychologist
Bereavement Support
Mental Health Services
Housing Support
Probation Services
Hospice
Health Services
Other
Prefer not to say
If other - please comment here
The following will help us to provide you with the right support. If you feel that your life or someone else's is in danger, please call 999 to seek immediate help from the emergency services. You can also contact HopeLineUK on 0800 068 41 41 or Samaritans on 116 123 or email
[email protected]
Over the past week how much have you (or the person you are referring) felt hopeless or like life is not worth living?
Always
Very Often
Sometimes
Rarely
Never
Do you feel you (or the person you are referring) are a danger to yourself or others?
Yes
No
Maybe
Prefer Not To Say
Other
If other - please comment here
Have you (or the person you are referring) made plans to end your life?
Yes
Yes but at a future date
No
Prefer not to say
Other
If other - please comment here
Please provide any additional information or share any concerns for yourself or the person you are referring. Including any mental or physical ill health or conditions that you feel are relevant.
*
If none, please put N/A
Your consent - by submitting this form and personal information you are permitting The Active Wellbeing Society (TAWS) to store your information and contact you by these means. The personal information that you provide here will only be used to arrange support and may be shared with our trusted partners as part of the Listen and Connect service. You also acknowledge that you have read our privacy notice (found on the footer of this website) and consent to TAWS processing your personal data in accordance with it. You will NOT be entered into any digital marketing emails.
*
I consent to the above (this is required to request this service)
Submit
