Waves professional referral - Suffolk Mind

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Self referral form

Waves professional referral

Before you continue, please note that we do not offer crisis support. If your client is in a crisis that puts their safety at risk, please visit our emergency contacts page.

Client name:(Required)

First Last

Client date of birth(Required)

DD slash MM slash YYYY

Postcode(Required)

Select address

Address (Line 1)(Required)

Address (Line 2)

Town/City(Required)

County

Country(Required)

Client's NHS number(Required)

Client email address:(Required)

Client phone(Required)

GP surgery name(Required)

(We only contact your client’s GP surgery in case of an emergency when accessing our service. If your client’s GP is not listed, please contact us on 0300 111 6000)

If you can't find your GP on this list, please let us know below.(Required)

Referrer name:(Required)

First Last

Organisation(Required)

Please tell us about your organisation:(Required)

Referrer email address:(Required)

Does your client have a diagnosis of BPD/EUPD?(Required)

Yes

No

Please tell us the year of diagnosis:(Required)

If no, please list your client's traits of BPD/EUPD:(Required)

Is your client aware that Waves is a group setting?(Required)

Yes

No

Is your client a veteran?(Required)

Yes

No

Does your client have any other mental health diagnoses?(Required)

Yes

No

If yes, please list your client's diagnoses (including year diagnosed)(Required)

Is your client neurodiverse?(Required)

Yes

No

If yes, please provide details:(Required)

Does your client have mobility issues?(Required)

Yes

No

If yes, please provide details:(Required)

Please note, we will contact you via email to acknowledge receipt of your referral form

I declare that the information provided by me is accurate to the best of my knowledge.(Required)

By submitting this form, I give permission for Suffolk Mind to process my client’s personal data inline with their Privacy Policy.

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Hit a low point?

Help directory Tell us how you feel

Privacy Policy
Suffolk Mind Impact Report
Anti Slavery Policy Statement
Reports and Accounts
Gender Pay Gap
Sitemap
Site by StrategiQ

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Who we help
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Need help now? Click here for crisis support

Need more info? 0300 111 6000

Need help now? Click here for crisis support

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