Referral Form - Intercom Trust

Step 1 of 4

WHO IS MAKING THIS REFERRAL?

Referral source(Required)

Are you requesting support for yourself, or requesting support on someone else's behalf?

I am requesting support for myself

I am requesting support for someone else

SAFETY CONCERNS
Safety concerns ?(Required)
Are there any risks we should be aware of for the person in need of support? Including self-harm, suicidal thoughts, homelessness, domestic violence and abuse (including sexual, financial, emotional, spiritual, physical abuse), risks to or from anybody else?

Yes [please specify]

No
Please specify
Please specify
Mental Health
[optional] If the person being referred is between the ages of 11-17 and living in Devon (including Plymouth and Torbay), have they been admitted to a hospital ward in the last 3 months due to concerns around their mental health?

Yes

No
Why do we ask this?

We are working with Young Devon to provide an In-Reach project where youth workers are able to support those who have recently been admitted to hospital and if answered ‘yes’ to the above question we may be able to help you self-refer to this service.
DETAILS OF THE PERSON MAKING THE REFERRAL
Name(Required)
Please enter the name of the person making the referral
First Last
Referrer Phone Contact(Required)
Referrer Email(Required)

Job title(Required)
Please enter your job title, or state NA if not relevant
Relationship to person being referred(Required)
Please enter your relationship to the person being referred
Referring Organisation
Please enter the name of the organisation making the referral (if relevant)
Address
Please enter the current address details of the person making the referral

Street Address Address Line 2 City County / State / Region ZIP / Postal Code

Consent(Required)
Please indicate your agreement to the following things before you click Submit. Please see our privacy page for more information if you need.
I understand that you will need to keep a record of this information, in accordance with Data Protection Law
I (the person in need of support) agree for you to contact me in accordance with my stated contact preferences
I (the referrer) agree for you to contact me

helpline: 0800 612 3010

helpline: 0800 612 3010

REFERRAL

WHO IS MAKING THIS REFERRAL?

REFERRAL DETAILS

DETAILS OF PERSON IN NEED OF SUPPORT

DIVERSITY

CONTACT

SAFETY CONCERNS

Why do we ask this?

DETAILS OF THE PERSON MAKING THE REFERRAL

Useful Links

Compliance

Zero Tolerance Policy