Information for Professionals Completing This Referral Form

This referral form is for professionals who wish to refer a person seeking support to Clear Mind Derby. Please complete all sections with as much detail as possible to help us understand the individual’s needs and ensure they receive the right support at the right time.

What we need from you

To process the referral effectively, please provide:

• Your details (name, role, organisation, contact information)

• Details of the person seeking support (contact information, preferred contact method, accessibility needs)

• Reason for referral and a brief summary of current concerns

• Any risks identified and whether other agencies are involved

• Relevant background information that will help us plan safe and appropriate support

• Consent confirmation that the person understands and agrees to the referral

Consent

Please ensure the person seeking support has given informed consent for this referral. If consent cannot be obtained due to risk or safeguarding concerns, please indicate this clearly in the relevant section.

What happens next

Once received, our team will review the referral and contact the person seeking support directly. We aim to do this within 5 working days.

We may also contact you if further information is required.

Please contact enquiries@clearmind -cic.co.uk if you require any information 

Thank you