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Make a Referral

Please note that people need to be a Salford resident or registered with a Salford GP to be eligible for the service.
Please note: For Secondary Care referrals, an up to date risk assessment must also be supplied, in addition to the referral form.

The referral will not be processed until the risk assessment is received.

If you are a referrer to the service and require further information please ring 0161 351 6000.

Return

Name of the service referring to START *

*required fields

Referrer Details*

Name*

Contact number*

Email address*

Which programme is your referral for? *

Inspiring Minds/Creative Arts

WINGS

Service user Details*

Full Name*

Date of birth*

Gender*

Female

Male

Prefer not to say

Email address*

Address*

Postcode*

Contact telephone number*

Is the service user currently employed?*

Yes

No

Unknown

Please confirm that the service user is available to attend our service on Tuesdays, Wednesdays or Thursdays for at least one of the following session times?*

10:00 - 11:30

12:30 - 14:00

14:30 - 16:00

Unknown

Emergency Contact Details*

Emergency contact name*

Emergency contact telephone number*

GP*

Name of service users GP Surgery*

Reason for Referral

Reason for referral to START*

Better manage mental and physical health

Improved resilience

Improved self-care

Improved wellbeing

Increased life satisfaction

Raised self-esteem, confidence and aspirations

Reduced stigma

Reduction in isolation and improved community connectedness

Other

Interpretation services*

Does the service user require access to interpretation services?*

Yes

No

Additional Questions

Is the service user accessing any of the following services?*

Acute Inpatient Services

Community Mental heath Team (Specialist Services)

Early Intervention Team

Health Improvement Service

Mental Health Liaison Service

Salford Neighbourhood Mental Health Service

Rehabilitation Services

Social Work Teams

No other services involved

If you have selected any of the additional services in the previous question, please provide information on specific services here, otherwise, please enter N/A*

Risk Assessment

Has a risk assessment already been completed?*

Yes

No

File upload

Please upload a copy of the completed risk assessment here* (PDF file only)

If no risk assessment has been completed, do you feel that one is necessary?*

Yes

No

If you have deemed it unnecessary for a full risk assessment, please advise if the service user is able to engage with our service and is currently stable*

Does the service user pose a risk to self?*

Such as suicidal ideation or attempts?

Yes

No

Risk to self

Please comment on the current situation

Does the service user pose a risk from substance misuse?*

Level or current alcohol / drug misuse

Yes

No

Substance misuse

Please comment on the current situation

Does the service user pose a risk to others?*

Such as behaviours / thoughts towards others including gender/race or religious ideas of concern. Any concerns about being in a group situation.

Yes

No

Risk to others

Please comment on the current situation

Does the service user pose a risk from self-neglect?*

Such as poor Self- care / nutrition issues etc.

Yes

No

Self-neglect

Please comment on the current situation

Is the service user at risk of exploitation or vulnerability?*

Yes

No

Exploitation or vulnerability

Please comment on the current situation

Does the service user pose a risk due to a probation or offence issue?*

Such as a restraining order / child or adult safeguarding concerns. Include historical information

Yes

No

Probation or offence issue

Please comment on the current situation. Include historical information

Is there any other important information which is not covered by the previous sections?*

Such as Medical conditions and any other information not covered in previous questions.

Yes

No

Any other information

Please comment on the current situation

Service User Consent to Disclose Information*

The service user understands the referral process and agrees that the information contained within this referral can be disclosed to the relevant workers within the organisation.*

The service user has given permission to be contacted by text in order to organise appointments etc.*

Please confirm by selecting this box, that you have highlighted any identified risk that START need to be aware of*

Special Field*