Online Mindfulness Course Referral

Data Storage *
By completing this referral form you are consenting to digital data storage of the information below and statistical data flow to the DoH (Department of Health) in accordance with GDPR 2018. For further information regarding this, please see our Policies under the Therapies heading at the top of this page.
Your Name *
Your Name
Your Address *
Your Address
Please enter the name of the surgery and not your GP.
Are you currently or have you been previously registered under the care of the Community Mental Health Team? *
If you answered yes to the previous question, please confirm if this is primary or secondary care. *
Gender *
Relationship Status *
Sexual Orientation *
How would you describe your nationality? *
How would you describe your ethnicity? *
Religious Group *
Do you have a disability? *
If you do not have a disability please insert "N/A" in the box below.
Long Term Conditions *
Do you have any of the following Long Term Conditions?
If you ticked "Other Medical Condition", please specify below.
Employment status
Do you have any military experience?
If you tick "Yes", further information will be required.
We assess risk and safety needs for all referrals. We do need to ask the following question to ensure you are able to keep yourself safe whilst on our waiting list: Have you had any thoughts of suicide within the past two weeks? *
If you have had thoughts of suicide within the past two weeks, please could you confirm if you have made plans to complete suicide? *
If you have made plans to complete suicide, do you have a time frame in place? *