Private and confidential
Initial Contact Form
Basic InformationName
Title D.O.B
AddressPost Code
Local Authority Reading Wokingham West Berks
Telephone
Today’s DateDescription of mental healthSupport code
Referral InformationReferral Body
Contact Person
Contact AddressPost Code
Phone
EmailReferral Documents Provided
Self ReferralHow did you hear about us?Action(e.g. Signposted)
Completed by Role:
Any follow up action
All documents are to be written alongside the client. The client must be aware of the contents within.
Private and confidential
Equality & Diversity
How do you describe yourself?Choose one section from A to E, then tick one box to best describe your ethnic group/background, then select one box in each of the other sections.
A White B Mixed / multiple ethnic groups
English/Welsh/Scottish/Northern Irish/British Irish Gypsy or Irish Traveller Any other white background, write in:
White and Black Caribbean White and Black African White and Asian Any other Mixed/multiple ethnic
background, write in:
C Asian / Asian British D Black / African / Caribbean / Black British
Indian Pakistani Bangladeshi Chinese Any other, write in:
African Caribbean Any other, write in:
E Other Ethnicity F Religion
Arab Do not wish to answer Any other ethnic group, write in:
Do not have a religion Christian Buddhist Hindu Muslim Jewish Sikh Do not wish to answer Any other religion, write in:
G Gender H Gender Identity
Male Female Do not wish to answer Prefer to use my own term, write in:
Gender identity is the same as the gender assigned at birth
Gender identity is different to the gender assigned at birth
Do not wish to answer
2
Private and confidential
Initial Contact Form
I Sexual Orientation J Disability
Gay Man Heterosexual/Straight Lesbian/Gay Woman Bisexual Do not wish to answer Prefer to use my own term, write in:
Physical ImpairmentPlease describe:
Sensory Impairment Learning Disability Long term illness or health condition
Please describe: Mental Health condition Do not wish to answer Any other disability, write in:
Accessibility/Communication NeedsDo you have any support needs affecting your access of our service or special communication requirements that you would like us to be aware of?How do you prefer to be contacted?Would you like to be on our mailing list?
Support NetworkGP
CMHT Worker
Other agencies
Personal network
Emergency Contact
Berkshire West Your Way, 1A Rupert Square, Reading, RG1 3HE. Telephone: 0118 9660 [email protected]
