South Somerset Mind Referral Form

Please click the following link to download the South Somerset Mind referral form or alternatively complete the following form and send directly to us.

Referral Form 

Referrer details:

Please provide us with your GP contact details:

Any other relevant agency in statutory services? Care coordinator, Therapist, floating support worker etc.


Diversity Monitoring Data (optional)

Please complete as many of the following questions as possible but if you do not wish to answer any question please skip to the next one.

please tick all that apply:


GDPR/Data Protection Privacy Notice

South Somerset Mind collects, processes and stores the personal data in this form (and collected while we provide support) for three reasons only. First, to contact you about your mental health and to arrange appointments. Secondly, to safeguard you and others in line with our legal obligations. Confidential information will only be disclosed if you are at risk of harming yourself or another person. Disclosure may only be made to your GP, your next of kin, statutory services, to or other mental health professionals. Finally, we use anonymised data to monitor diversity and to provide statistics to those who fund and regulate us. South Somerset Mind may share data with other local Mind associations or with Compass Disability Services (with whom we work in partnership) for the same purposes only. You have the right to request a copy of the data we hold on you by writing to us or emailing us. Complaints can be made in writing or by email by contacting us in the usual ways. All data will be held for ten years from the date a referral is made. 

All personal information will be added to our secure online database. The information you have provided to us will be kept strictly confidential.

Declaration by referrer (or person requiring service if self-referral)

 


Contact Us

South Somerset Mind
Unit 4, Yeovil Small Business Centre,
Houndstone Business Park,
Yeovil, BA22 8WA

01935 474875
info@southsomersetmind.co.uk

Get Social

Twitter
Facebook
Youtube