This referral has NOT been sent yet. You will be redirected to the listing's external referral form. Please complete the referral form there to submit the referral confirm Details Ealing Safe Space by Hammersmith & Fulham, Ealing and Hounslow Mind Who is this referral for? I am signing up myself I am referring someone else Service access criteria Tick to confirm you have checked the service access criteria "Anyone who feels they are nearing crisis, including carers 18 or overLive in, or access a GP in EalingCare for someone who lives or accesses a GP in EalingHammersmith & Fulham residents can visit our Hammersmith & Fulham Safe SpaceHounslow residents can visit our Hounslow Safe Space " Your Details Email Email is invalid We already have an account with this email. Please log in. Password Reset my password Log in First name Last name Your relationship to the person Organisation name Who are you referring? First name Last name Known as Date of birth Email Don't know / client doesn't have an email address Phone Address Line 1 Address Line 2 Town/City Postcode GP surgery NHS number Additional referral details Do not enter protected health information (PHI) or any other personal data in these fields. What are the reasons for this referral? Sedentary lifestyle High body weight Finances Caring responsibilities Loneliness/isolation Employment Food Poverty Covid/Long Covid Mental health Substance misuse Transport Legal advice Managing a long-term health condition Day-to-day helping hand Victim of abuse Housing problem Bereavement Other: This field is required. Should the service provider be aware of any additional needs? Blind/partially blind Memory problem Hearing loss Housebound Does not speak English Poor mobility Learning and communication needs Physical disability Frail Other: Please share some brief details regarding this referral Confirmation and consent Tick to confirm you have gained consent to share this information with the service provider, your organisation and Joy Tick to confirm the service provider can directly contact the client Would you like to create an account? Make referrals faster next time you use Joy. Registered users can message service providers, submit reviews and track the progress of their referrals online. Password Weak password! Use at least 8 characters Use upper and lowercase characters (a-z) Use 1 or more numbers (0-9) Confirm password Please enter the same value again. required Submit Email: Password: Email
