Well-being and Mentoring Referral Form

Wellbeing & Mentoring Referral Form

Please be aware that Arcus only offers online video confrencing & telephone sessions.

Date of referral *

Full Name *

Date of birth *

What are your preferred pronouns? *

Phone *

House number & Street Address *

Town/City *

County *

Post Code *

Country

Please note when we contact you, the call will come from a withheld number. If you do not answer we will leave a voicemail unless you tell us not to. If we can't leave a voicemail and are still unable to contact you we will default to your email address. *

I have voicemail and you can leave me a messageI do not have voicemail/please don't leave me a message

The best time to contact me is: *

MorningAfternoonEvening

How would you like to be contacted? *

TelephoneEmail

Name address and phone number of GP *

Can you please give a name and number for somebody we can contact in an emergency on your behalf: Please note we will not contact this person unless we have a serious concern for your safety.

Do you have any physical or mental health problems that may affect wellbeing & mentoring sessions? *

Do you take any regular medication that may influence your wellbeing and mentoring or that we may need to know about? *

Do you consider yourself to have a disability & if so do you require any additional support to access our service? *

Are there any other agencies or organisations involved with your ongoing care that we may need to know about? *

Please briefly tell us here what you would like to talk about with your support worker *

If you are a purchaser of hours with an existing service level agreement or a Welfare Scheme please indicate this here

This referral is via the PHD Welfare SchemeThis is a Family Help ReferralThis is a Social Prescribers ReferralThis a Darlington Carers referral

If you work for PHD, please enter your staff number here:

Referrer Details

If you are the person requesting support you do not need to complete this. Only complete this part if you are referring someone else.

Referrer Name

Referrer Organisation

Referrer Contact Number

Referrer Email

Confirmation *I have read and agreed to the terms and conditions and privacy policy.

Confirmation *I understand that I will receive an automated email with the Well-being and Mentoring agreement detailed.

Confirmation *I am aware that this service is means tested in order to ascertain the correct fee level and that there may be a charge for services

Confirmation *I am aware that if I do not respond to calls/voicemail/emails when contact is attempted that my referral will be closed.

Confirmation *If I am referring a third party I have made them aware of the fees /or / I am the client.