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Barnet Wellbeing Hub External Referral Form

Individual’s Details

Full Name

Date of Birth

Gender

Telephone No.

Mobile No.

Email

Street Address

Street Address Line 2

Postcode

NHS No.

Consent to Use Address

Consent to Leave Voicemail

Consent to Text

Consent to Email

Have they accessed the Barnet Wellbeing Hub before?

Yes

No

If Yes, when did they access it?

Is an Interpreter Required:

Yes

No

If Yes, which language?

Referrer’s Details

Name

Job Title

Address

Telephone No.

GP Details

GP Name

Consent to Contact GP

Yes

No

Surgery Details

Emergency Contact

Full Name

Relationship

Telephone No.

Reason For Referral

Desired Outcome/s

Any physical/ Mental health issues we need to know about?

Risk (Past/Present, Risk of Harm to Self, to/from Others, Self-Neglect/Neglect of Others, Alcohol/Drug Use)

Emotional Health Check

Has an Emotional Health Check Been Completed:

Yes

No

Outcome of Emotional Health Check:

Issues

Benefits (Goals)

Actions

Your Signature

Select a date

Thanks for submitting!

For further information and queries please contact us on 03333 44 9088 or email us at info@barnetwellbeing.org.uk

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