Referral Form

Please refer to our guidelines or contact us with any queries. You can attach additional information. This form is for our Adult Mental Health service. There is a different form available for those interested in Sow & Grow, our Dementia project. Use this link to access the Sow & Grow Dementia Referral form.

Note to referrer. The contents of this form are treated as confidential by our organisation; however please ensure that your client is happy for this information to be shared with our staff. Some of the data on this form will be converted to data stored on a computer retrieval system in accordance with the data protection act 1998.

Patient/Client details
Name*
Date of Birth*
Date Format: DD slash MM slash YYYY
Address
Tel (Home)*
Mobile
Email
In which of the project’s activities has your client expressed the most interest?
- Art & Craft
- Garden
- Sow & Grow (Dementia)
- Growing Lives
Main reason for referral (incl. medical diagnosis)
Other health problems we should be aware of e.g. insulin dependent diabetes, epilepsy, heart condition, back pain etc
History of violence/aggression, drug/alcohol abuse, self-harm (please include a risk assessment if one is in place by using the file upload section of this form)
Are they currently on CPA?
- Yes
- No
If yes, Care Co-ordinator’s Name:
Care Co-ordinator’s Address
Care Co-ordinator’s Phone
Care Co-ordinator’s Email
Important: Please complete this section in full even if you have made a previous referral to Sydenham Garden.
Referrer Details
Referrers Name*
Position
Organisation*
Address including postcode*
Phone*
Email
Signature
Date
Date Format: MM slash DD slash YYYY
Other Support
Name
Position / relationship
Organisation
Address including postcode
Tel
Email
File
Please tick if you have made a prior referral to Sydenham Garden and your contact details have changed in the last six months.
- Yes
Please tick if you would like to know if your client has been invited to an introduction. NB We can only do this if you supply your email address.
- Yes
Please tick to confirm that your client consents to Sydenham Garden processing their personal data*
- Yes
Transparency notice to be shown to your client: Sydenham Garden (SG) records certain information about you. This information is overseen by SG’s Data Controller (currently Coralie Hopwood). The Data Controller can be contacted at the Resource Centre Office. We record your name, address and telephone details as well as details of an emergency contact. We also record your mental health diagnosis and important information (such as a risk assessment) sent to us by the health professional who referred you, in order to give you the safest care possible. The legal basis for holding this information is called ‘legitimate interest’. We will hold your records for a further 6 years after you complete your time as a co-worker with us, in line with NHS policy. We will never pass your information onto an external individual or organisation without seeking your consent first. While reports on the effectiveness of the charity’s work are sent to funders including Lewisham CCG and Lewisham Council, it is not possible to identify individuals from these reports. You have the following rights relating to the information that we hold about you: -A right to see the information we hold on you (access). SG will agree to your request as soon as practicably possible and not later than 1 month from the date of the request. -A right to request any errors in your information are corrected (rectification). SG will agree to your request as soon as practicably possible and not later than 1 month from the date of the request. -A right to request your information is erased from Sydenham Garden’s records (erasure). If there is no good reason for SG to hold your information, SG will agree to your request to erase the information it holds on you. However, while you are a co-worker, there will be a continuing good reason to hold the information to help us to provide you with the best care possible. -A right to complain to the Data Controller using the SG Complaints Procedure. If you feel we have not responded correctly to your request please follow the SG Complaints Procedure. Should you not be satisfied after using our complaints procedure you have a right to complain to the Information Commissioners Office via: https://ico.org.uk/concerns/ or by the Helpline on 0303 123 1113.

Patient/Client details

Referrer Details

Other Support

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