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 MindPath (Ryedale) by Scarborough Whitby and Ryedale 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 "MindPath is open to anyone aged 16+ who is experiencing mild to moderate mental ill health, or is looking to build up their self care and improve lifestyle health. This is a prevention and early intervention service and not suitable for anyone experiencing severe mental illness or crisis." 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? This field is required. Should the service provider be aware of any additional needs? Please share some brief details regarding this referral Preferred contact method Telephone Email This field is required. When is the best time to contact you? Morning Afternoon Evening Permission to leave a voicemail message/send a text? Yes No This field is required. Are you experiencing problems/issues with any of the following? Money Housing Work Relationships Long term health condition Caring responsibilities Domestic Abuse This field is required. On a scale of 1-10 (with 1 being 'not at all' and 10 being 'very much') please indicate how much these problems impact on your ability to go about your daily day-to-day life? Select1 2 3 4 5 6 7 8 9 10 Do you consider yourself to have a disability, neurodiversity or long term health condition? Yes No This field is required. If you have a disability, neurodiversity or long term health condition please provide brief details Do you have any alcohol or drug related problems? Yes No This field is required. If you have any alcohol or drug related problems, please provide brief details Are you a veteran? Yes No This field is required. Are you accessing any other mental health services? Community Counselling Next Steps Survivors Community Mental Health Team Crisis Team Horizons Living Well As an equal opportunities organisation, we would like to ensure we meet your needs; do you have any specific requirements which would assist us to do this? Do you consider yourself to be a risk to yourself or others? If yes, please explain. Would you like to receive occasional email briefings or newsletters about upcoming services and events at SWR Mind? * Community Counselling Next Steps Survivors Community Mental Health Team Crisis Team Horizons Living Well Yes No This field is required. Is there anything else you would like us to know (i.e. background/history)? 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
