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Referral Form

Referral Form

Referrals are open for all groups.  We are working with a backlog, so please bear with us.

Please see our referral eligibility criteria or contact us with any queries.

Please note, this form is for referrals to our Adult Mental Health service and is only for Primary Care practitioners with clients based outside Lewisham, or for Secondary Care practitioners.

If your client is a Lewisham resident please see the section on the How To Make A Referral Page.

There is a different form available for those interested in Sow & Grow, our Dementia project.

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 General Data Protection Regulations and Data Protection Action 2018.

Find out more information about our current groups, including timings.

A. Personal Details

Please complete client/patient's details below:
DD slash MM slash YYYY
Gender(Required)
This is the preferred contact number - it can be a mobile or landline
It is very helpful for us to be able to communicate by email, if possible.

B. Referrer

Referral supporting information provided
Please attach supporting information using the form upload function in section E.
Will you/your team continue to work with the client?(Required)

C. Wellbeing

Mental health diagnosis?(Required)
Are there any other physical health concerns that we should be aware of? E.g. insulin dependent, diabetes, epilepsy, heart condition, back pain, medication side effects etc.(Required)

D. Risk

E. Sydenham Garden groups and support needs

Has your client attended a group at Sydenham Garden in the past? Which group(s)?(Required)
Please note that we are not able to consider referrals from people who have already completed two or more project placements with us.
Which group(s) is your client most interested in?(Required)

F: Diversity Monitoring

As part of our monitoring processes we ask for your co-operation in completing the questions in this section. Sydenham Garden is committed to the principles of fairness, consistency, and equality of opportunity. No person will be discriminated against because of their age, disability or ability, ethnicity, gender or gender identity, religion or belief and / or sexual orientation, or if you prefer not to complete this section. The information you enter on this form will be used for monitoring purposes only and all reporting will be anonymous. Data is kept securely in line with current data protection legislation.
Consent(Required)
Please tick this box to confirm your client's consent for Sydenham Garden to store and process the information given below to report anonymously on demographic and diversity data for the organisation. Please ask your client to answer the following questions:
Gender(Required)
Sexuality(Required)
Ethnicity(Required)
Religion(Required)
Disabilities & Health Conditions(Required)
Are you registered disabled with the local authority?(Required)
Drop files here or
Accepted file types: jpg, png, pdf, doc, xls, , Max. file size: 256 MB.
    MM slash DD slash YYYY
    Please tick to confirm that your client consents to Sydenham Garden processing their personal data(Required)
    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. 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.

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    Printable Referrer Resources