Self Referral Form

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Please note: all Headway Somerset services accessed via this referral form are paid for services. Our support groups remain free to attend (donations welcome), and you do not need a referral form to join them.

Please indicate your type of referral.

Details of the person or organisation making this referral*

Please provide: Your Name – Contact Details – Organisation Name – Organisation Contact Details

Date of referral

Patient name*

Carer Name & Contact Details*

Date of birth*

Address*

Telephone number*

Email address of patient/carer *

Details and effects of Brain Injury. Any other medical conditions. (Please note that the brain injury must be the prominent factor and reason for referral).*

Mental Health and Wellbeing/ Diagnosed mental health conditions*

History of Self harm

Current risk to others

Current Self Harm

None

Previous harm to others

Current Suicidal intent

Previous Suicide attempt

Other

Potential risks related to home visits e.g. history of domestic violence, pets, state of home*

Transport needs (Please note HSX are not responsible for arranging transport)*

Any other information which may be relevant

Name & contact details for any other professional or specialist involved (Social Worker / Physio / SALT / OT/Community Rehab Team / Community Nurse)

Please indicate which services you are interested in:

Hospital Liaison

Support Group

Activity Group

Counselling

Futures Group

Outreach

If interested in our Activity Hubs, Outreach service, please indicate how the placement will be funded?

Consent*

This information is correct to the best of my knowledge

By submitting this form, you confirm that you have obtained consent from the named individual for their personal data to be stored and processed by Headway Somerset in accordance with our Privacy Policy.

This information will be securely stored and used to contact the designated individual. To help Headway Somerset support the named individual more effectively, we may need to share information with and receive information from other parties involved in their support.

All information will be kept strictly confidential and will only be accessible to staff on a need-to-know basis.

Headway Somerset Registered Charity Number: 1097407

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