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Roshni Ghar
Making equality in mental health care a reality
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Referral Form
Section 1: Personal Details
First Name
*
Last Name
*
Date of Birth
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Day
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Month
Month
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Year
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1932
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2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
Street Address
Street Address Line 2
City
Postal Code
Country
United Kingdom
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Bouvet Island
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Carribean Netherlands - Bonaire, Sint Eustatius and Saba (Netherlands Special Municipalities)
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo, Republic of the
Congo, The Democratic Republic of the
Cook Islands
Costa Rica
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Côte d’Ivoire
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Eswatini
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
French Southern Territories
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island and McDonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran, Islamic Republic of
Iraq
Ireland
Isle of Man
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
Korea, Democratic People's Republic of
Korea, Republic of
Kosovo
Kuwait
Kyrgyzstan
Lao People's Democratic Republic
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macao
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia, Federated States of
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
North Macedonia
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine, State of
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Barthélemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin (French part)
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Sint Maarten (Constituent Country of the Netherlands)
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia and the South Sandwich Islands
Southern Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard and Jan Mayen
Sweden
Switzerland
Syrian Arab Republic
Taiwan
Tajikistan
Tanzania, United Republic of
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United States
United States Minor Outlying Islands
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Åland Islands
State/Province
Phone Number
Preferred Language
Afrikaans
Albanian
Arabic
Bangla
Bulgarian
Catalan; Valencian
Chinese (China)
Chinese (Taiwan)
Czech
Danish
Dutch (Netherlands)
English (Australia)
English (Canada)
English (United Kingdom)
English (United States)
Estonian
Finnish
French (Canada)
French (France)
German
German (Swiss)
Greek, Modern
Hebrew (modern)
Hindi
Hungarian
Indonesian
Italian
Japanese
Khmer
Lithuanian
Norwegian Bokmål
Punjabi
Persian (Iran)
Polish
Portuguese (Brazil)
Portuguese (Portugal)
Romanian, Moldavian, Moldovan
Russian
Serbian
Slovak
Slovene
Spanish; Castilian (Spain)
Spanish; Castilian (Mexico)
Spanish; Castilian (Puerto Rico)
Swedish
Telugu
Thai
Turkish
Ukrainian
Urdu
Vietnamese
Dutch (Belgium)
Section 2: General
Date of Referral
*
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
Year
2020
2021
2022
2023
2024
Is there a recent risk assessment?
Yes
No
Details of risk assessment
Have they accessed Roshni Ghar before?
Yes
No
Is the client aware of the referral?
Yes
No
Can we contact them directly?
Yes
No
Name and role of other professionals involved
Does client have a CPA plan?
Yes
No
Section 3: Referrer Details
First Name
*
Last Name
*
Job Title
Organisation Name
Phone Number
*
Email
*
Section 4: Medical / Clinical Details
GP name
Practice/medical centre
Relevant medication
Summary of mental health diagnosis / history
*
Diagnosis
*
Agoraphobia
Anxiety
Asthma
Bipolar
Blood pressure
Cholesterol
Depression
Diabetes
Eating disorder
Hearing voices
Isolated
Loneliness
Long term health condition
Low mood
Obsessive Compulsive Disorder
Panic attacks
Psychosis
Schizophrenia
Self harm
Stress
Section 5: Dependants / Carers
Name
Relationship (dependant or carer?)
Name 2
Relationship (dependant or carer?) 2
Name 3
Relationship (dependant or carer?) 3
Section 6: Reason for Referral / Additional details
*
Section 7: Monitoring Information
Ethnicity
- None -
Pakistani
Bangladeshi
Arab
Indian
White/British
Afro/Caribbean
Other
Disability impacting daily life?
- None -
Yes
No
Not disclosed
Marital Status
- None -
Divorced
Long term partner
Married
Other
Single
Widowed
Gender
- None -
Female
Male
Other
Transgender
Sexuality
- None -
Gay
Lesbian
Bisexual
Heterosexual
Other
Not disclosed
Not asked
Religion
- None -
Muslim
Christian
Jewish
Buddhist
Sikh
Atheist
Humanist
Jain
Other
Details of the Roshni Ghar Data Protection Policy can be found here:
Data Protection Policy
Consent
*
Yes - I/the individual described here has given consent to Roshni Ghar to record sensitive personal information
No - I/the individual described here has NOT given consent to Roshni Ghar to record sensitive personal information
Consent to share with other Organisations
Yes - I give my consent to Roshni Ghar to access and share my personal information with other relevant service providers for the purposes of helping me with my mental health and wellbeing needs
No - I do not give my consent to Roshni Ghar to access and share my personal information with other relevant service providers for the purposes of helping me with my mental health and wellbeing needs