Referral Form

Lancashire Wellbeing Service
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GUIDANCE NOTES

This form is to help us understand your current situation and how we may be able to support you.

We will keep all information in line with our confidentiality policies.

Our programme accepts self-referrals and supported self-referrals (in other words, if you are making this on behalf of someone else, they will be completing this form with you).

WHAT TO DO NEXT?

I am completing this form about myself

If you need help with completing the form, or if you have any questions, please call 03450 138 208. Also, please tell us about any services who you are working with already. We won’t contact anyone without your permission.


I am being supported to make a self-referral by someone else

Please ensure that you put the details of the person supporting you on the form so that we can contact you both to discuss the referral.


If I am not the person I'm referring

Please call the engagement team first on 03450 138 208 to discuss. We can talk about the best way of making a referral with you.

* Required
REFERRING AGENCY/SURGERY GP DETAILS - referring agency please complete this section
ABOUT ME (or you if someone is helping you fill this form out)
BEST WAYS TO GET IN TOUCH?
Contact Numbers
JUST A LITTLE MORE INFORMATION - THANK YOU
Thinking about why you are contacting us, please tick the boxes you feel are relevant to your life currently.
Do you have a social care package/worker?
Are you on the waiting list for a social care assessment?
Do you have a worker from a statutory Mental Health Service?
Are you on the Waiting List for a statutory mental health service?
Are you on any long term medication for a diagnosed mental health condition?
Do you have parental responsibility for or live with any children under the age of 18?
Employment status
IS ANYONE SUPPORTING YOU AT THIS MOMENT IN TIME?
GENERAL DECLARATION
We would like to be able to support you with this referral therefore we ask for your permission to share the information on this form with our wellbeing workers. This will only be used to enable us to understand your situation and see what support would suit you best.