Wellbeing Exeter Adult (18+) Professionals Referral Form

Wellbeing Exeter and Cranbrook Professionals Referral Form

Referrals via Voluntary Sector, Social Care, Higher Education and Health Professionals etc.
Date of Referral:*

DayMonthYear
Date
Who is this referral for?*

Exeter Adult (Aged 18+)Cranbrook Adult (Aged 18+)Cranbrook FamilyCranbrook Young Person (Aged 11-17)
Wellbeing Exeter & Cranbrook works with individuals who have the capacity and understanding to make informed decisions on their own behalf or with the support of others. If you are uncertain about whether the individual meets this criteria, please contact us directly to discuss before submitting this referral form.
Consent
Has the individual / appointed representative given consent for their details to be shared with Wellbeing Exeter & Cranbrook?*

Yes (please proceed with referral)No (do not proceed with referral and go back to individual)
Does the individual / appointed representative give consent to work with Wellbeing Exeter & Cranbrook?*

Yes (please proceed with referral)No (do not proceed with referral and go back to individual)
Person's Details

Please note that we can only take referrals in the Exeter area for adults aged 18+. Cranbrook area covers adults aged 18+, families and young people. If the referral is for a Family in Cranbrook, please share the details of an adult, NOT the details of any child within the household.
Name:*

First NameLast Name
Preferred Name (if different from above):

First NameLast Name
NHS Number (if known):
Date of Birth:*

DayMonthYear
Gender:*
Preferred Pronouns:
Address:*

Address Line 1

Address Line 2

CityCounty

Postcode
Phone Number:*

Area CodePhone Number
Email:
Contact Preferences (tick all that apply):*

PhoneVoicemailTextWhatsAppEmailLetter
Young Person Referral Only (Cranbrook)

Please fill in this section if this referral is for a Young Person (aged 11-17) in Cranbrook - if not, then move on to the next section.
School / College Attended:
If the young person is aged 11-13, we require their parent / carer's contact details here:
Parent / Carer's Name:

First NameLast Name
Parent / Carer's Relationship:
Parent / Carer's Phone Number:

Area CodePhone Number
Parent / Carer's Email:
Carer Information

Please fill in this section if applicable - if not, then move on to the next section.
Does The Person Have A Carer?

YesNo
If So, Carer's Name:

First NameLast Name
Carer's Phone Number:

Area CodePhone Number
Is The Person A Carer?

YesNo
If So, Give Details:
Disability & Other Issues
Is The Person Registered Disabled?

YesNo
If Yes, Give Details:
Does The Person Have any Sensory / Communication Issues?

YesNo
If Yes, Give Details:
Referrer's Details
Referrer's Name:*

First NameLast Name
Referrer's Job Role:*
Referrer's Place of Work:*
Referrer's Phone Number:*

Area CodePhone Number
Referrer's Email:*
Where did you hear about Wellbeing Exeter & Cranbrook?*
Referral Needs
Please tick all that apply:*

SocialEmotionalPracticalPhysical Health / DisabilityPhysical Activity
Reason For Referral
Please give brief details of your reasons for referring this person. Please ensure the person has consented for the following information to be shared with Wellbeing Exeter & Cranbrook:*
Other Referrals Made
Please give brief details of other relevant referrals you have made for the person or any agencies that are already involved with supporting the person (i.e. DPT, CAMHS, social care etc):
Risk Awareness
Are there any risks we should be aware of, such as:

SafeguardingLone WorkingDrug AbuseMental Health IssuesDomestic ViolencePhysical Activity / Health IssuesOther
If you selected Other above, please give details below:
Disclaimer: Wellbeing Exeter & Cranbrook reserves the right to limit, suspend or refuse services to anyone based on our professional opinion, and at our discretion at any time, and without giving details or reasons.
Should be Empty:

Wellbeing Exeter and Cranbrook Professionals Referral Form

Consent

Person's Details

Young Person Referral Only (Cranbrook)

If the young person is aged 11-13, we require their parent / carer's contact details here:

Carer Information

Disability & Other Issues

Referrer's Details

Referral Needs

Reason For Referral

Other Referrals Made

Risk Awareness