Please complete the referral form below.

Data Sharing Statement

Some of the data we collect from you at your Talkzone referral will be shared with the NHS as part of our funding agreement. This data includes your date of birth, postcode, gender and GP surgery but does NOT include your name or the reason you have made the referral.

To find out more information about how your data is used, or to opt-out from additional data tracking and research, please visit the website https://www.nhs.uk/your-nhs-data-matters/

Who is making this referral?

UK Data Protection Laws requires our organisation to manage all personal information in accordance with the General Data Protection Regulations. In particular, we are required to process your personal information fairly, lawfully and in a transparent manner. This means that you are entitled to know how we intend to use any information you provide. You can then decide whether you want to give it to us in order for us to provide the service or services that you require.

In accordance with GDPR all of the information we request and collect is for the legitimate purpose of accessing our services. All contact information will be used to contact you with details of service and or services that you have requested. Your personal details will not be retained for any other purpose.

All of our staff are responsible for maintaining your confidentiality. As an organisation we provide training to all members of staff and ensure that they are aware of their obligations. In addition to this our policies and procedures are regularly audited and reviewed.

If you would like to update the information we hold for you, change the methods by which you would like us to contact you or if you would like to have your information removed from our records please contact us at info@centreplace.org.uk or write to us at The Centre Place, Abbey Street Community Centre, Abbey Street, Worksop, S80 2LA

Today's date

Your name

Are you a parent/ carer or professional?

Parent/carer

Professional

If Professional:

Your full name:

Role and relationship to young person:

Job Title:

Organisation:

Contact number:

Email address:

Consent

Is the young person aware of and consented to this referral?

Yes

Does the young person show a willingness to engage in support for their mental health?

Yes

If no, please explain further:

Are parents carers aware of and consented to this referral?

Yes

If no, please explain further:

Young Person's Details

Young persons legal name:

Young persons preferred name:

Young persons date of birth:

Day

Month

Year

Young persons address:

Country/Region

Address

City

Zip / Postal code

What are the young persons preferred pronouns?

Young person's gender identity

Is the young persons gender identity the same as the one assigned at birth?

Yes

Prefer not to say

Young Person's Sexual Orientation

Does the young person have an EHCP (education, health care plan)?

Yes

Not applicable

Does the young person have any SEN needs? (special educational needs)

Yes

Not applicable

GP Information

Name of GP practice:

Address of GP practice:

Phone number of GP practice:

Details of any other professionals or organisations you are working with, or on a waiting list for.

Please provide the name of the organisation, the address and the reason for the support.

Parent/ carer information

Parent / Carers Name:

Parent and Carers address:

Same as young person

Different to above

If different from young person, please specify:

Contact details

Preferred person to contact regarding this referral?

Parent / Carer

Young Person

If parent and carer:

Mobile number:

Is it ok to

Leave an answerphone message

Send a text message

Please do not leave any messages

Call

If young person:

Mobile number:

Is it ok to

Leave an answerphone message

Send a text message

Please do not leave any messages

Call

Preferred method of contact:

Phone call

Text

Reason for referral:

Please tell us about why you are making this referral:

It is helpful for us to know what the young person is feeling, how it is impacting on their life, how long they have been feeling like this and if they have had any support already.

What are your aims of attending the service?

Do you have any health conditions, disabilities or access needs you want to tell us about?

We want to make sure we do our best to accommodate these.

You understand that the young person will be contacted by Talkzone and failure to respond may result in the young person being discharged from the service.

You understand it is your / the young persons responsibility to update Talkzone with any changes to personal information, such as address and phone number.

You understand data will be sorted electronically and securely in line with Talkzone's GDPR procedures.