Referral form

Welcome to Reach Out Camden

Thank you for starting a referral with Reach Out Camden. This form helps us begin to understand your needs and how we can best support you. You don't need to answer every question, but some key details are required so our team can get a clear picture of how to help. Required questions are clearly marked.

Please note that we currently have a waiting list of 6-9 months for our one to one support service offers

If you have any questions while filling out the form or would like to learn more about our services, please don't hesitate to get in touch. We're here for you.

Need help with this form? 🤔

If you need any help filling out this form, we're here to support you. You can contact the Reach Out Camden team via phone or email.

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This field is for validation purposes and should be left unchanged.

My language 💬🌏(Required)

My language 💬 (if not listed)

The interpretation service we use does not cover all languages. If your language is not represented in the drop down menu above, please write in this free text box what language you require

Do you require an interpreter?(Required)

Yes

Please note, interpreters are available – including British Sign Language (BSL) – if your preferred/first language is not spoken English

Please enter the language you feel most comfortable communicating in.

If you are making this referral/filling out the form on someone else’s behalf, please enter that person’s preferred language.

If you use or prefer to use sign language (e.g., BSL – British Sign Language) or another non-spoken language, please enter this in the box above.

Who is filling out this form?(Required)

I am filling out this form for myself

I am filling out this form on behalf of someone else

Someone else is helping me to fill out this form on my behalf

I can confirm that I am…(Required)

A current resident of Camden

Registered with a Camden GP

Please note, we can only accept referrals from people who meet at least one of the above criteria.

What is the name of your GP practice?(Required)

The person I am referring/filling out this form for is…(Required)

A current resident of Camden

Registered with a Camden GP

Please note, we can only accept referrals from people who meet at least one of the above criteria.

What is the name of their GP practice?(Required)

Consent Declaration(Required)

I have this person’s consent to fill in this form and submit their details on their behalf

Referrer Details

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Referrer Address (combined)

Your (Referrer) Name(Required)

Address Line 1

Relation to client(Required)

Address Line 2

Town/City

Postcode

Phone Number

Alternative Phone Number

Organisation(Required)

Please enter “N/A” if not applicable

Your Role/Job Title(Required)

Please enter “N/A” if not applicable

My details

Client’s details

First Name(Required)

Last Name(Required)

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Pronouns (combined)

Pronouns(Required)

Pronouns are used to refer to someone in the third person e.g he/him, she/her, they/them – we ask this to know how to respectfully refer to you

Preferred Name

Other Pronouns

Date of birth 📅(Required)

I am 18 years of age or above

Date of birth 📅(Required)

Client is 18 years of age or above

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DOB (combined)

Day(Required)

Month(Required)

Year(Required)

🔞 Please note, we cannot accept referrals for anyone under the age of 18

My contact details

Client’s contact details

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Address (combined)

Phone Number

Address Line 1(Required)

Alternative Phone Number

Address Line 2

City/Town(Required)

Postcode(Required)

Preferred communication methods 💬(Required)

Phone

Post

Text

Please tick all that apply.

Please also note, we require you to select at least one preferred communication method (and provide the set of contact details for this) – this is so we can keep in touch about your referral.

Best day / time for us to call you? 📞📅

Please let us know if there is a particular time during the week that is best to call. We will try to call you during this time where we can

Trusted Contact

This is someone who you would be comfortable for us to contact in the case of an emergency – e.g., a friend, relative, or healthcare professional.

Please enter your trusted contact’s details in this section (or the details of the trusted contact for the person you are referring/filling this form for).

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Trusted Contact Address (combined)

Name(Required)

Address Line 1

Relation to you(Required)

Address Line 2

Town/City

Postcode

Phone Number(Required)

Alternative Phone Number

My Hopes

I am hoping to access…

Emotional support – Support to help process feelings, build coping strategies, or just have someone to talk things through with

Social support – Access to groups, social activities and peer networks to build connection and belonging

Practical support – Help managing forms, bills, housing, benefits and other admin tasks

Other

Please tick all that apply

Other hopes – please describe

If you have other hopes, desires or needs for what you would like to get out of your referral with us, please give a short description of these in the box above

Are any other services currently supporting you with your well-being?

Yes

Prefer not to say

What other services are currently supporting you with your well-being?

Please list each name of the service and type of support you are receiving in the space provided

Services available at Reach Out Camden

Please tick which services you are interested in. If you are not sure which support may suit you at the moment, you can discuss this with one of our Reach Out Navigators who will be in touch – select all that apply

One-to-one support

Group activities / support

Peer Support

Not sure

Do you already know which specific services offered by Reach Out Camden that you need?

Yes

If you already know which service (or services) you need, please select below:

Healthy Minds Community Programme

Likewise Community Programme

Likewise 6-8 service

Voiceability Peer Mentoring

Mind in Camden Social Prescribing

Please tick all that apply

My Needs

What extra help, if any, do you need to access services?(Required)

Please detail any accessibility requirements you may have in the above space.

Please enter “N/A” if not applicable or you do not wish to share.

Is there any information that would be useful for someone working with you to be mindful of?(Required)

Please enter “N/A” if not applicable or you do not wish to share.

Is there anything that might affect your safety or the safety of others?(Required)

Please enter “N/A” if not applicable or you do not wish to share.

Is there anything else you would like us to know?

e.g. anything about your hopes, interests or needs that you would like to share

My Demographics

The information below helps us to understand who contacts our services and whether or not this is reflective of Camden’s diverse community. It helps us to know who we’re reaching and where we can improve.

Completing these questions is optional and the information you provide will not affect the service you receive.

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Ethnicity (combined)

Ethnicity

Please select one option

Asian / Asian British

Black / African / Caribbean / Black British

Mixed / Multiple ethnic groups

White

Other ethnic group

Prefer not to say

Asian / Asian British

Please select one option

Indian

Pakistani

Bangladeshi

Chinese

Other

Black / African / Caribbean / Black British

Please select one option

African

Caribbean

Black British

Other

Mixed / Multiple Ethnic Groups

Please select one option

White and Black Caribbean

White and Black African

White and Asian

Other

White

Please select one option

White English / Welsh / Scottish / Northern Irish / British

Irish

Gypsy or Irish Traveler

Roma

Other

Other ethnic group

Please select one option.

Please select “Other” and use the space provided to specify your ethnic group (if this is not listed)

Arab

Other

Religion

Please select one option

Buddhist

Christian

Hindu

Jewish

Muslim

Sikh

No religion

Prefer not to say

Other

Gender

Please select one option

Female

Male

Non-binary

Prefer not to say

Not sure

Other

Do you identify with the gender you were assigned at birth?

Yes

Prefer not to say

Sexual Orientation

Please select one option

Asexual

Bisexual

Heterosexual

Gay / Lesbian

Prefer not to say

Not sure

Other

How did you hear about Reach Out Camden(Required)

Please select one option from the list below

Word of mouth

Your GP

Mental health practitioner

Other health professional

Social worker

Care navigator

Website

Newsletter

Poster/Leaflet

Reach Out Camden event

Other

Which website did you hear about us from?

The Advocacy Project – http://www.advocacyproject.org.uk

Camden Council – http://www.camden.gov.uk

Likewise – http://www.likewise.org.uk

London Waiting Room – http://www.londonwaitingroom.nhs.uk

Mind in Camden – http://www.mindincamden.org.uk

Stay Alive – http://www.stayalive.prevent-suicide.org.uk

Voluntary Action Camden (VAC) – vac.org.uk

Voiceability – http://www.voiceability.org.uk

Other

Privacy Statement

It’s important that you are completely confident with how your personal information will be looked after during your time working with Reach Out Camden. The statement below outlines the information we take, how it’s used and who will have access to it. If at any time you have questions or concerns about how we look after your personal information, please contact us on +44 20 7241 8984 or at Webadmin @reachoutcamden.co.uk

1. The information we collect
We only collect information that is necessary to provide our services, and we promise to look after it. On the referral form, we collect general personal details as well as equality, diversity and inclusion data, which you have the right to choose not to share. When we start working with you, we may take notes relating to our work with you and we may also collect information from other services or individuals in your support network.

2. What we do with it
We use this information to provide our services across Reach Out Camden. We may also use it to evaluate and improve our services. We are required to provide anonymised equalities data to Camden Council. We only keep information as long as is reasonable and required by social care guidelines. You have a right to access your information at any point and request for us to delete or amend it.

3. Does anyone else see my information?
In order to provide you with our services, there may be times when we need to share some of your information with our partner organisations or relevant members of your support network. The only other time we may share your personal information is if it is required by law, or to protect against harmful or illegal activity.

Privacy declaration(Required)

By ticking this box you confirm that you have read our Privacy Statement and agree to your data being used in this way*