LTC Professional Referral form

Please only complete this form if you are a professional making a referral for a patient with a diagnosed long term physical health condition to the Supporting Minds team. Alternatively, you can download and complete this form.

    Patient Details:

    Referrer's Details:


    YesNo

    Next of Kin/Emergency Contact Details:

    Referral Information

    Long term physical condition:
    For each condition,please tick and give the date of diagnosis:

    COPD / Respiratory Disorder

    Diabetes

    MSK Problems

    Chronic Pain

    Cardiovascular Disease

    IBS

    ME

    Fibromyalgia

    Mental Health Problem:

    Anxiety

    Panic Attacks

    Depression

    Excessive worrying

    Unhelpful or distressing thoughts

    Other - please give details:

    Please confirm your details below if you give consent for your details to be shared.

    I give my consent for the information contained in this referral to be shared with the Supporting Minds team.