Professional Referral

communitymindthrive.org

6th Floor, First Central 200, 2 Lakeside Drive, Park Royal, London NW10 7FQ

0203 638 9416

07354 860896

info@communitymindthrive.org

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Community Mind Thrive

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Community Mind Thrive – Professional Referral Form

Community Mind Thrive is not a crisis service. If the individual is in immediate danger, please contact NHS 111 (Option 2), 999 or attend A&E.

Professional Referral Form

Referrer Name

Organisation

Job title

Contact Number:

Service User Details

First Name

Last Name

Address

Address Line 1

Address Line 2

City

Postcode

Date of Birth:

Reason for Referral

Primary reason for referral:

Presenting issues:

What support is being requested?

Risk & Saftey

Is the individual currently in crisis?

Yes

Is the user at risk to self or others?

Yes

Is the individual safe at present?

Yes

Any safeguarding concerns?

GP & Services

GP Registered?

Yes

Not known

GP Practice (if known):

Currently receiving other support?

Yes

Details (if known)

Consent

Has the individual consented to this referral?

Yes

Date of Consent

HOW CAN WE SUPPORT YOU?

Please choose the option that best describes your enquiry:

Self Referral

Partner With Us

Volunteer

Community Mind Thrive

Community Mind Thrive delivers scalable, community-based mental health support that reduces system pressure, prevents crisis escalation, and improves population health outcomes.

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info@communitymindthrive.org

0203 638 9416

07354 860896

6th Floor, First Central 200, 2 Lakeside Drive, Park Royal, London NW10 7FQ

Community Mind Thrive is not a crisis service. If you need urgent care, or you or someone you know is in danger. Please call 999 or go straight to A&E 24/7 mental health crisis line: Call NHS 111 and select the mental health option Call Samaritans on 116 123 (UK-wide) or Text SHOUT to 85258 (UK-wide)

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