Patient/client information required for online referral form to Growing Well

Below is a summary of the questions asked. If you are unable to answer all questions (or need to answer “Don’t Know” to any questions), we will require a further reference from another professional in order to gather all information and progress the individual’s admission to Growing Well.

Personal and contact information
Name; Date of birth; Gender; Ethnicity
Full address and Postcode; Telephone number; Email; Preferred method of contact

Mental health and medical information
Mental health diagnosis (if relevant)
Do you know if this person has received, or is currently receiving, support from mental health (or other) services? (Yes – please specify/No/Don’t know)
Is this person taking any medication linked to their mental health condition? (Yes – please specify/No/Don’t know)
Does this person have any other medical conditions that we should be aware of, in relation to the activity? (Yes – please specify/No/Don’t know)

Risk management
Is there a known risk of aggression/violence? (Yes – please specify/No/Don’t know)
Is there a risk to lone workers/staff? (Yes – please specify/No/Don’t know)
Does the person have any criminal convictions? (Yes – please specify/No/Don’t know)
Is the person registered under the Sex Offenders Act 1997? (Yes – please specify/No/Don’t know)
Is the person a regular user of alcohol or drugs? (Yes – please specify/No/Don’t know)
Does the person self-harm / have suicidal ideation? (Yes – please specify/No/Don’t know)
Is the person working with any other agencies to reduce risk to self or others? (Yes – please specify/No/Don’t know