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Referral Assessment
*
1.
Name
(Required.)
2.
Referral Source
Self Referral
GP
Care Merseyside
Other (please specify)
3.
Gender
Male
Female
Prefer not to say
Other (please specify)
4.
age
18-24
25-34
35-44
45-54
55-64
65+
5.
Area of GP
Liverpool
Knowsley
Sefton
Wirral
Other (please specify)
6.
Referral Reason (click more than one if appropriate)
Low Mood
Anxiety
Stress
Financial Support
Education
Isolation
Addiction
For Carer Support
Other (please specify)
7.
Please rate your current need in each area (1 need support / 10 - do not need support)
1
2
3
4
5
6
7
8
9
10
Stress levels
1
2
3
4
5
6
7
8
9
10
Anxiety
1
2
3
4
5
6
7
8
9
10
Low mood
1
2
3
4
5
6
7
8
9
10
Finances/housing situation
1
2
3
4
5
6
7
8
9
10
Physical well-being
1
2
3
4
5
6
7
8
9
10
Mental Health education
1
2
3
4
5
6
7
8
9
10
Relationships with others
1
2
3
4
5
6
7
8
9
10
Self esteem
1
2
3
4
5
6
7
8
9
10
Addiction
1
2
3
4
5
6
7
8
9
10
Other (please specify) and give rating 1-10
8.
What form of support would you prefer (please tick all that apply)
Individual 1-1 sessions
Group Sessions
Online Zoom Sessions
Support group
Other (please specify)
9.
What workshops would you be interested in attending
Mindset & goal setting
Mental Health Awareness
Stress & Anxiety management
Mindfulness & Relaxation
Low self esteem & Building Resilience
Financial Well-being
Addiction
Loss and Relationship breakdown
Physical well-being & Positive habits
*
10.
Please leave your email address below and one of the Evolving Mindset Team will contact you as soon as possible.
(Required.)
Email Address
*
11.
I understand that Evolving Mindset are not a Clinical Mental Health Service - we still advise to seek advice from your GP or professional team. We are a community interest network that can provide bespoke education and support for people experiencing mild to moderate mental health concerns and/or carers. We are also able to signpost you to other support networks which may be best suited to support your needs.
(Required.)
Agree
*
12.
I understand that It is a basic principle of Evolving Mindset that we offer confidentiality to participants.
I agree to maintain confidentiality of others when accessing support from Evolving Mindset
(Required.)
Agree
