Talkzone Self Referral | The Centre Place

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/

Consent

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

Young Persons declaration:

• I give consent for The Centre Place - Talkzone Mental Health Service to share my details with relevant professionals /organisations to help the Talkzone service to give me accurate and appropriate support.

• I agree that information provided will be stored on a secure database for a minimum of 7 years and to be used anonymously for monitoring purposes.

I agree

Today's date:

Full legal name

Preferred/chosen name

If different from above.

Is your gender identity the same as it was assigned at birth?

Yes

Prefer not to say

Your date of birth

Day

Month

Year

Referrals can only be accepted from your 11th birthday up until your 25th birthday.

Address

Country/Region

Address

City

Zip / Postal code

Do you have any Special Educational Needs? (SEN

Yes

Prefer not to say

Do you have a Education Health Care Plan (EHCP)?

Yes

Prefer not to say

If yes, please share any additional information:

GP Information

Name of GP practice

Please be aware your GP must be a Bassetlaw GP for your referral to be accepted. If you need help in finding a suitable service please call our office.

Address of GP practice

Please include postcode

Phone number of GP practice

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

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

Emergency contact information

Name of emergency contact

This should be a trusted adult, preferably someone who has responsibility for you such as a parent or carer.

Relationship to you:

Does this person live at the same address as you?

Yes

If no, please specify:

Phone number of emergency contact:

Is this person aware that you are referring to Talkzone?

Yes

Do we have permission to contact your emergency contact?

Yes

If you are under 16 years of age, we cannot process the referral without consent to contact someone in case of emergency. In safeguarding situations, if you are under the age of 16 we will be required to contact your parents or carers.

How can we best contact you

Phone

Can we call you on this number?

Yes

Can we leave a voicemail?

Yes

Can we send a text message?

Yes

Reason for referral:

Please tell us why you are making the referral?

It is helpful for us to know what you are feeling, how it is impacting your life, how long you have been feeling like this and whether you've had any support already.

What are your aims for attending the service?

Please tell us what you want to achieve from accessing mental health support.

Have you accessed Talkzone previously for support?

Yes

Please note that we would recommend a break of at least 6 weeks before re-referring if you have accessed recently.

Do you have any disabilities, health conditions or access needs that it would be helpful to tell us about?

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

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

I understand that my data will be stored elecronically and securely in line with Talkzone's GDPR procedures.

I understand it is my responsibility to update Talkzone with any changes to my personal details, such as address and phone number.

Thank you for submitting your referral to Talkzone. We aim to be in touch within 5 working days. If you have any questions or queries, please call the office on 01909 479191.