Listen & Connect Referral Form – The Active Wellbeing Society

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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 *

Age *

Employment Status *

Main Language Spoken *

Ethnic Background *

Have you (or the person you are referring) used this Listen and Connect service before? *

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)
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

Do you (or the person you are referring) have any physical or mental health conditions or illnesses lasting or expecting to last for 12 months or more?

Yes
No
Prefer not to say

What type of condition do you (or the person you are referring) have? Tick all that apply

Vision (e.g. blindness or partial sight)
Hearing (e.g. deafness or partial hearing)
Mobility (e.g. walking short distances or climbing stairs)
Stamina/breathing/fatigue
Dexterity (e.g. lifting and carrying objects, using a keyboard)
Learning Disabilities (diagnosed)
Learning Difficulties (reading, writing, processing info, understanding)
Memory
Autism/Asperger's Syndrome
Mental Health
Other

If other - please specify 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. *

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)

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0121 728 7030

Manor House, Hay Hall Business Park, Redfern Road, Tyseley, Birmingham,
West Midlands, B11 2BE.

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The Active Wellbeing Society Limited (registered no.7595) is a charitable community benefit society

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