Open Door Professional Referral Form

Referrer Details

Name of referrer's service *

Name of referrer *

Contact details of referrer *

Date of referral 12345678910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember *

COLLAR number and department if GMP Officer (i.e. MASSH/Response). If not applicable please state N/A *

Referred Person's Details

Person's name *

Person's date of birth 12345678910111213141516171819202122232425262728293031 JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember 2026202520242023202220212020201920182017201620152014201320122011201020092008200720062005200420032002200120001999199819971996199519941993199219911990198919881987198619851984198319821981198019791978197719761975197419731972197119701969196819671966196519641963196219611960195919581957195619551954195319521951195019491948194719461945194419431942194119401939193819371936193519341933193219311930192919281927192619251924192319221921192019191918191719161915191419131912191119101909190819071906*

Person's contact number *

Person's email *

Person's address *

Person's preferred contact method Text Phone Email Post *

If a different method is preferred, please give details here

Consent for Open Door to contact the person on the methods above *

Person's GP surgery (if known)

Referral Details

List any of the known diagnosed Mental Health conditions, including Depression, Anxiety, Trauma, Schizophrenia, Bi-Polar Disorder, Personality Disorder, Bereavement or any not listed (please specify which) *

Does the person have any issues within the following areas? Housing, Employment, Relationships, Financial, Wellbeing, Addiction, Physical Health and any not listed (please specify which) *

Main reason for referral/current crisis (and if open to secondary or professional team, what support you would like Open Door to offer) *

Have you identified any risk to the person, such as Self-Harm, Suicidal intent, Risk from others, Risk to others (please specify which) *

If you've provided any risks in the previous question, please provide details of the known risk, including risk to themselves or to others (if no further information is available please state this)

Detail safeguarding measures already completed and by who *

Any other relevant information

Consent

I confirm that I have consent to send over the person's details to Open Door and the person is aware that we will reach out to contact them *

Exclusion criteria

Below are reasons why we would reject a referral that comes into the service and reply requesting further information before any contact is made with the person.

• Missing information on referral form - No information in the risk to self/others section, no details of what the crisis is, no contact details or no consent to refer
• Service specific exclusion criteria - The person is under the age of 18, active suicidal ideation where the person may require hospital admission, requiring assessment under S136 of the Mental Health Act or requiring medical attention for physical needs