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Veterans Mental Health Referral Form

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Veterans Mental Health Service

If you need help completing this form, please call our service

Veterans Mental Health Referral Form

Client Information

This address is: *
Text Message?*
Voicemail Message?*
Email?*
Relationship Status: *
Communication Difficulties?*

Armed Forces History

Branch of Armed Forces:*
Regular or Reserve:*
Are you currently enlisted?*
Were you deployed operationally?

GP Details

Referrer Details (not a self-referral)

Next of Kin

(e.g. partner, family member, friend,neighbour, etc)
Is it OK for them to be contacted?*

Support/Carer

Do you have a carer/family member/friend that supports you day-to-day?*
Do you care or support anyone else?*

Other details

Have you had previous mental health problems and/or contact with mental health services?*
Do you feel there are significant risk issues to yourself or others?*

Our service does not provide emergency care. In the event of an emergency you are advised to contact your GP, local crisis number, attend your nearest A&E Department or dial 999

Are you using alcohol?*
Do you smoke?*
Are you using illicit substances?*
Do you have children*
Do they live with you?*
Do you have any physical health problems?*
Do you consider yourself to have a disability?*
Do you have accessibility needs?*
Are there other services currently involved in your care (eg. RBL, STOLL...)?*

Consent

I give permission for the Veterans’ Mental Health TIL Service (TILS) and Complex Treatment Service (CTS) to verify my military service with the MOD and if necessary to request copies of my service and/or medical records (e.g. from DCMH, PRU and/or DMS).*
I give permission for my medical records from my General Practitioner (GP) to be provided to the TILS & CTS.*
I understand that I have the right to withdraw my consent at any time by:
  • Speaking to staff at the TILS or CTS
  • Letter (4th Floor, West Wing, St Pancras Hospital, 4 St Pancras Way, London, NW1 0PE)
  • Phone (0203 317 6818)
  • Email (cim-tr.veteranstilservice-lse@nhs.net)
*
I give permission for my information to be used anonymously for research and service evaluation purposes.*
I give permission for my information to be shared with my General Practitioner (GP).
We are unable to proceed with your referral if you do not consent for us to share information with your GP*

Terms & Conditions

Information shared with the services indicated above shall be: the minimum necessary; in compliance with both the Data Protection Act (2018) and the General Data Protection Regulation (GDPR, 2016); and accessed only by appropriate staff on a need to know basis.

This referral will be reviewed by our service within 48 hours of the completed referral form being received, after which time you shall be contacted by a member of the service.

Veterans' Mental Health TIL Service

4th Floor, West Wing, St. Pancras Hospital, 4 St Pancras Way, London, NW1 0PE

Tel: 020 3317 6818

Email: cim-tr.veteranstilservice-lse@nhs.net