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 Wellbeing Team - Barnstaple Alliance by Barnstaple Alliance I am signing up myself I am referring someone else Service access criteria Tick to confirm you have checked the service access criteria "16+ w/o complex mental health needs" 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 What are the reasons for this referral? Caring responsibilities Loneliness/isolation Employment Food Poverty Housing problem Debt/money options Having difficulties with or in need of benefits Family/ relationship issues Fitness issues Issues that mean individuals are approaching threshold for social care Immigration and cultural difficulties Low Mood or Low-Level Anxiety Patients who frequently access NHS services Patients who show mild symptoms of anxiety and/or depression Patients with long term conditions that could benefit from individualised support Where a medical solution or intervention is unlikely to be successful or satisfactory 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 Do you have any concerns about any possible risk to staff? I don’t have any concerns. I would have concerns. Don’t know the patient well enough to comment. 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
