Here For Each Other staff wellbeing service team member referral form

Please use this form to refer a member of your team or a colleague to the Here For Each Other staff wellbeing service.

• If you are here to refer yourself to the staff wellbeing service, please use our self-referral form.
• If you are here to refer a whole team to the staff wellbeing service, please use our team referral form.

This online referral form is fully secure and all details below will be stored on our secure and confidential system. By completing this form you agree to these terms and to be contacted via any available method.

Return to the "Here For Each Other" staff wellbeing website.

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Your name *

Your phone number *

Your email address *

Your job role *

Which service do you work in? *

Which organisation do you work for? *

Please confirm that the person you want to refer is aware and consents to the referral *

YES No

We are sorry, but we cannot continue the referral without their consent

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Tell us about the person you are referring into the Wellbeing Hub

Their first name of the person you are referring *

Their last name *

Their date of birth *

January February March April May June July August September October November December 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 1991 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022 2023 2024 2025 2026 2027 2028 2029 2030 2031

Their work email address *

Their personal email address

Their phone number *

Their home address *

Their job role *

The service they work in *

The organisation do they work for *

Their nationality *

British English Irish Scottish Welsh Other

Their ethnicity *

White - British White - Irish White - Any other White background Mixed - White and Black Caribbean Mixed - White and Black African Mixed - White and Asian Mixed - Any other mixed background Asian or Asian British - Indian Asian or Asian British - Pakistani Asian or Asian British - Bangladeshi Asian or Asian British - Any other Asian background Black or Black British - Caribbean Black or Black British - African Black or Black British - Any other Black background Other Ethnic groups - Chinese Other Ethnic groups - Any other ethnic group Not Stated - I do not wish to state Not known - Not known

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Have they ever received treatment or support from mental health services? *

Yes No Don't know

Please tell us briefly about that support

Please give us an outline of why you're referring this person to the Wellbeing Hub *

Thank you for completing the form. Please press 'submit' and send your referral through to us.

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