Make a referral

Completing the following referral form should take 10-15 minutes. We ask a range of questions about various aspects of your mental health and your life in general. We appreciate that it might seem like a lot of questions to answer but the information you provide allows us to offer you the right services for your needs.

If you would like further information please email us on spoe@mindchwf.org.uk.

Due to government guidelines on Covid-19 and social distancing, we have been working alongside our partner organisations to create an alternative offer of online support that can be accessed remotely.

Please complete the referral form and screening questions and you will be given access to these resources. You will be offered free access to a wide of range of online resources that focus on the management of anxiety, low mood and stress.

This new online offer of support will include:

Access to online self-help modules in the NHS approved Silvercloud programme.
Access to bespoke online webinars & videos created by experienced therapists and wellbeing practitioners.
Participation in peer groups

Please note that you will not be contacted for an assessment to access this online support. We’ll send you an email with an access link to each resource as and when they become available.

If you are at immediate risk please contact emergency services or go to A&E. For urgent support or if you are in crisis or distress please contact the City & Hackney Crisis Pathway Service 24 hour helpline on 020 8432 8020.

Please note our mental health and wellbeing services are only available to people who live in the borough of Hackney or the City of London.

Residents of Waltham Forest are able to access our Rainbow Mind, IRIE Mind, education, employment and welfare rights services. If you do not live in Hackney or the City of London please contact your local Mind.

Contact details

Please enter your client's contact information

Title*

First Name*

Surname/Family Name*

Pronouns

Other Pronouns

Address*

Street Address City ZIP / Postal Code

Borough

Mobile Number

Please enter the mobile number without spaces

Other contact number

Email address

GP Surgery

Name of the GP you see most regularly

Please leave blank if you do not see one GP regularly. Name of the GP you see most regularly

NHS Number

If you do not know your NHS number please leave this blank

Do you need an interpreter?

Yes

No

Interpreter language

Digital Inclusion

Do you have access to an internet enabled device such as a smartphone, tablet, laptop or desktop computer?

Do you have access to a stable internet connection?

Which of the following best describes your use of the internet?

Please consider using email, video chat software i.e Skype or Zoom and navigating websites or apps

Would support to improve your digital skills be helpful?

Do you have concerns around security or privacy when using the internet?

Demographic details

Date of Birth

Gender*

What is your ethnicity?

Sexual orientation

Religion

Employment status*

Benefits status

Accommodation status*

Do you consider yourself to have a disability?

Filling out the following questionnaires will help us to determine the right kind of support for you, if you would prefer to discuss them with a member of our team please leave them blank and submit your referral.

(For referrers who are unable to complete these with the person they are referring please enter all scores as 0)

Below are some statements about feelings and thoughts.

Please enter the number that best describes your experience of each over the last 2 weeks based on the below:

= None of the time
= Rarely
= Some of the time
= Often
= All of the time

I have been feeling optimistic about the future