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 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.