Back

Brighton & Hove Wellbeing Service Referral

Brighton & Hove Wellbeing Service Referral


  • 1
  • 2
  • 3
  • 4
  • 5
  • 6
  • 7
  • 8
  • 9
  • 10

Note: All fields marked with a red * are mandatory.

About the referrer

We accept self-referrals and referrals from clinicians and professionals. If you are making a referral on behalf of someone else please ensure that you fill this form out with the service user rather than on the service user's behalf.

Please note: We use the data you provide in this form to help us make the best decision for your care, and to ensure that we are the right service for you. We will keep this information as part of our records of our work with you. All information we hold about patients is held securely.

Are you making this referral for yourself, or are you a professional making a referral for somebody else? (please indicate which option)*

Statements

This referral form is for people aged 18 and above. Please consider a referral to our CYP service if you, or the person you are referring, is aged 4 - 17 years.

Before completing this referral form, please confirm whether each of the following statements apply:

I am over 18 (or completing this referral for someone who is over 18)*

This referral form is for people aged 18 and above. Please consider a referral to our CYP service

I am currently living in Brighton and Hove and / or am registered with a Brighton and Hove GP*

Our service is for people living and/or registered with a GP in Brighton and Hove. Please use the NHS website or liaise with your GP to find an appropriate service in your area.

I am able to manage my own safety and do not require crisis support to do so*

Our service does not provide emergency or crisis support. If you need urgent help or are in crisis please click here.

I am seeking support solely for a drug or alcohol problem*

If you are solely seeking support for a drug or alcohol problem please contact CGL.

Referrer Details

About the clinician or professional referring

If you are a clinician or another type of professional please ensure that you fill this form out with the service user rather than on the service user's behalf.

Referrer Contact Details

In order to process referrals from a professional, the referral must have been agreed with the service user. Has this referral been agreed with the service user?

Service User Details

About the Service User

This referral form is for people aged 18 and above. You will find support for people aged below 18 years here, please consider a referral to our CYP service

BWS staff will need to contact you by phone. Do you consent to the service contacting you (them) by:

Landline: *
Mobile: *
SMS/Text: *

We require permission to use at least one contact method in order for you to complete this referral

BWS staff will need to contact you by email or post. Email addresses will only be used to communicate about appointments or share questionnaires, relating to your care. Do you consent to the service contacting you (them) by:

Email: *
Post: *

Do you consent to the service leaving voicemail messages on the numbers provided?

Landline: *
Mobile: *

Service User Demographics

We gather this information for monitoring reasons so that we can understand which groups are accessing our service. Your responses to these questions will not affect your treatment within the service. You are not required to answer these questions - if you do not wish to answer these questions please select 'Prefer not to say' or 'Do not wish to disclose'.

Service User Details

About the Service User

Do you require an interpreter: *

Do you (the service user) have difficulties in any of the following areas?

Hearing: *
Sight: *
Speech: *
Mobility: *
Learning Disability: *
Other: *

Please indicate if any of the following circumstances apply to you, as this may support how we respond to your referral

You are a veteran of the armed forces: *
You have children under the age of 1 year, or are pregnant, or are the partner of someone pregnant: *
Are you currently a student? *
Are you a refugee/Asylum seeker? *

Service User Details

About the Service User

You must be either be registered with a GP or live in our servive area to complete this referral

Service User Details

About the service user's current difficulties

It is important to tell us about your current difficulties with as much information as possible, as it will help ensure you access the right service to meet your needs.

If you are not sure, or your difficulty is not included on the list, please select "other". The questions that follow this one will give you an opportunity to provide us with more detail.

Are you currently receiving support from any other mental health services?*
Please tell us if you use other substances?*
Are you currently taking any medication for your mental health? Please include both prescribed and over the counter medications: *

GAD-7

About your current symptoms

Please complete the questionnaires below relating to your experiences over the last two weeks. The GAD-7 and PHQ-9 are questionnaires which help to assess and monitor symptoms of low mood and anxiety, and your answers will help us to find the most suitable support or treatment offer for you.

Over the last 2 weeks, how often have you been bothered by any of the following problems:

Feeling nervous, anxious or on edge: *
Not being able to stop or control worrying: *
Worrying too much about different things: *
Trouble relaxing: *
Being so restless that it is hard to sit still: *
Becoming easily annoyed or irritable: *
Feeling afraid as if something awful might happen: *

PHQ-9

Over the last 2 weeks, how often have you been bothered by any of the following problems:

Little interest or pleasure in doing things: *
Feeling down, depressed or hopeless: *
Trouble falling or staying asleep, or sleeping too much: *
Feeling tired or having little energy: *
Poor appetite or overeating: *
Feeling bad about yourself - or that you are a failure or have let yourself or your family down: *
Trouble concentrating on things, such as reading the newspaper or watching television: *
Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual: *
Thoughts that you would be better off dead or of hurting yourself in some way: *

Current Safety

About your current safety

You have told us you are currently experiencing some thoughts about self-harm or suicide. We need to understand how these thoughts are currently affecting you. We understand that answering the following questions may be distressing, and if this is the case, would encourage you to make use of available crisis and support services.

https://www.brightonandhovewellbeing.org/urgent-support

Have you recently made any plans to harm yourself or end your life?*
Have you harmed yourself recently?

If you feel you are in a mental health crisis and are at immediate risk please call Mental Health Rapid Response on 0300 304 0078 – this phone line is available 24 hours a day 7 days a week.

Other health conditions

Do you have any of the following long-term physical health conditions?

Chronic Obstructive Pulmonary Disease (COPD): *
Chronic pain, including fibromyalgia: *
Coronary Heart Disease: *
Hypertension (high blood pressure): *
Insulin dependent diabetes mellitus: *
Non-insulin dependent diabetes mellitus: *

How did you hear about us?

BWS information sharing statements

Do you consent to us sharing information with your GP? *


I (the person being referred) am aware that if the Brighton and Hove Wellbeing team conclude another service may be more able to offer treatment or support, my referral may be discussed in a multi-service triage meeting. Relevant information may be gathered and shared with services including Assessment and Treatment Services, Wellbeing and UOK Brighton & Hove. I (the person being referred) may be contacted directly to be offered an assessment or support by one of these services.

Do you agree to your referral potentially being taken to the multi-service triage hub and understand you may be contacted by another service to be offered and assessment or support? *
Are there any services you do not want information to be shared with? *