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 Bucks Mind, Wellbeing Groups - Aylesbury by Buckinghamshire 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 "Adults aged 18+ living in Bucks, who are experiencing daily challenges due to moderate to severe mental health difficulties." 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: Key Worker (name, email & phone number) Funding Source SelectFunded: £22.71 for 1 session Funded: £47.87 for 2 sessions + Self-Funded: £19.50 per session Funding Status SelectNot yet applied for Applied for but not yet approved Applied for and approved Self funding If funding is approved, date from: If funding is approved, LAS number: Location and day named person wishes to attend Aylesbury Monday Aylesbury Wednesday Aylesbury Thursday Chalfont St. Peter Tuesday Chesham Monday Chesham Friday High Wycombe Tuesday High Wycombe Friday This field is required. Current Support Plan (e.g. diagnosis, care visits/activities etc.) Current Risk (within six months) Harm to self Harm to others Harm from others Accidents Other risk behaviours This field is required. Historic Risk (more six months ago) Harm to self Harm to others Harm from others Accidents Other risk behaviours This field is required. If YES to any of the above (Risks) please give concise summarised details: Early Warning Signs: How can we prevent a crisis and manage it if it occurs? 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
