Referral Form

Refer yourself or someone you know.

Welcome to the Women's Work Heart Project!

The project supports women with domestic abuse, emotional well-being, substance misuse, low-level mental health, and other needs. As the programme is structured and focused on personal development, it is important that participants are able to attend regularly and engage with the sessions. If you would like to make a referral, please complete the referral form below.

Please allow up to 10 working days for referrals to be processed.

Step 1 of 11

Today's Date(Required)

DD slash MM slash YYYY

Please input the date of making the referral

Please Complete(Required)

I am referring myself

I am a professional making a referral

I am referring a friend / family member

Select an option.

What is your level of mental health difficulty?(Required)

Low

Moderate

High

Have you been under any of the following services in the last 12 months?(Required)

Mental health team

Crisis Team

Community Psychiatric Nurse (CPN)

Any other mental health specialist services

Crisis Support Information

If you are currently experiencing high levels of mental health difficulty (such as crisis, suicidal thoughts, or severe emotional distress), our service may not be the most appropriate support at this time.

The Women’s Work Heart Project is not a specialist mental health service, which means we are not able to provide the level of clinical support that may be needed. We want to help you access the right support for your situation.

You can contact the following specialist services directly:

NHS Mental Health Support (24/7) Call 111 and select the mental health option
Derbyshire Mental Health Crisis Team (24/7) Phone 01332 623900
Derby Safe Haven (evening crisis support) Phone 0330 008 3722
Samaritans (24/7 emotional support) Phone 116 123 or email jo@samaritans.org
SANEline (specialist mental health support) Phone 0300 304 7000
Shout Crisis Text Support Text SHOUT to 85258

If you feel at immediate risk, please call 999 or attend your nearest A&E department.

What is the level of mental health difficulty of the person being referred?(Required)

Low

Moderate

High

Referrer's Contact Details if Not Self-Referring

Referrer's Name(Required)

First Last

Organisation

Position

Landline Number

Mobile Number(Required)

Email(Required)

Has the person been under any of the following services in the last 12 months?(Required)

Mental health team

Crisis Team

Community Psychiatric Nurse (CPN)

Any other mental health specialist services

Crisis Support Information

You can contact the following specialist services directly:

NHS Mental Health Support (24/7) Call 111 and select the mental health option
Derbyshire Mental Health Crisis Team (24/7) Phone 01332 623900
Derby Safe Haven (evening crisis support) Phone 0330 008 3722
Samaritans (24/7 emotional support) Phone 116 123 or email jo@samaritans.org
SANEline (specialist mental health support) Phone 0300 304 7000
Shout Crisis Text Support Text SHOUT to 85258

If you feel at immediate risk, please call 999 or attend your nearest A&E department.

Details of Person Being Referred

Full Name(Required)

First Last

Date of Birth(Required)

DD slash MM slash YYYY

Email(Required)

Phone(Required)

Address(Required)

Street Address Address Line 2 City ZIP / Postal Code

Please select all methods we can safely contact you by(Required)

Phone Call

Text Message

Letter

Are there any contact issues?(Required)

For example times when you are not able to pick up a call, if you have no email access,..

Additional Information

Is English the first language of the person being referred?(Required)

Yes

What is the first language of the person being referred?(Required)

Is interpreter required?(Required)

Yes

Unfortunately, we are not able to provide interpreters

Ethnicity(Required)

Religion(Required)

Sexuality(Required)

Does the person referred have any access issues or disabilities(Required)

Yes

Disability details(Required)

Eg. Do you require ramp to access the building or any other adjustments?

Children under 18

Does the person referred have any children?(Required)

Yes

No, but currently pregnant

Number of Children

Do the children live with the person referred?(Required)

Yes

Please provide the names and ages of children, and any further details:(Required)

Do the children have any learning needs? Does the person referred have parental responsibility

Is Social Care Involved?(Required)

Yes, but unsure of the level

Yes - Initial Referral

Yes - Early Help

Yes - Child in Need

Yes - Child Protection

Yes - Public Law Outline

Name and contact details of Social Worker(Required)

Health & Additional Information

Which GP surgery are you registered with?(Required)

Do you have any physical health condition?(Required)

Eg. Epilepsy, diabetes

Do you have any allergies?(Required)

Yes

Please provide details(Required)

Do you have any mental health diagnosis? Please provide details(Required)

What have you been diagnosed with? Do you take any medication for this?

Do you have any Neurodevelopmental Conditions/ Learning Disabilities(Required)

eg. Autism, ADHD, Tourette's, Dyslexia

Categories of Support Required

Please indicate areas of support required(Required)

Abuse, Rape & Domestic Abuse

Confidence, Self-Esteem & Emotional Wellbeing

Families & Relationships

Sexual Health & Sexual Exploitation

Skills, Education & Employment

Finance, Benefit & Debt

Substance Misuse

Accommodation

Mental Health

Physical Health

Offending Behaviour

Delivery methods: Group-based programmes mainly, some 1:1 and virtual options, signposting

Please share some background and any relevant information about the person being referred and they think they will benefit from our service(Required)

You can also include that you would like to access Freedom Programme or any other specific programme, or tell us what support you are looking for at the moment.

Why do you feel now is the right time for you to engage on this project?(Required)

What are you hoping to achieve from attending this project?(Required)

Do you have a clear goal you would like to work towards?

How did you hear about the service?(Required)

Word of Mouth

Social Media

Professional

Google Search

I've previously used your services

Other

Other:

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Home | Get Support | Referral Form

Refer yourself or someone you know.

Welcome to the Women's Work Heart Project!

You can contact the following specialist services directly:

Referrer's Contact Details if Not Self-Referring

You can contact the following specialist services directly:

Details of Person Being Referred

Additional Information

Children under 18

Health & Additional Information

Categories of Support Required

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