You can make a referral to an Islington Mind service by going to the relevant page and clicking the
Referral Form button, or by using the buttons below.

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Day Centres
Drop-in sessions, group activities, peer support groups, IT rooms, ad-hoc support from staff and a point of contact in our organisation

Refer to
Day Centres

Refer to
Day Centres

You can write "Prefer not to say" for any information you would rather not give.

Date of referral *

Name of person being referred *

Pronouns

Date of birth *

Address *

What borough do you live in?

Telephone Number *

Email

Gender *

Marital Status *

Ethnic group *

Sexual orientation *

Religion/Faith *

Employment Status/Skills *

Are you a carer? *

• Yes
• No

Do you provide regular unpaid care to an adult friend or family member?

What is Your Mental Health Condition? *

Any other disabilities/health problems

Medication

GP Surgery

GP Phone

Psychiatrist's Name

Psychiatrist's Address

Psychiatrist's Phone

Emergency contact person

Relationship to you

Emergency contact's phone

Do you have any criminal convictions? *

• Yes
• No

If Yes, please provide more details

Do you have any history of drug/alcohol abuse?

• Yes
• No

If Yes, please provide more details

What other daytime activities are you involved in?

Which Islington Mind services are you interested in? *

Are you self-referring? *

• Yes
• No

Name of referrer *

Referrer's Address *

Name of referring agency

Referrer's Email *

Referrer's Phone/Mobile

Does the service user give consent for this referral to be made? *

• Yes
• No

How did you hear about our service? *

Submit

CovidRecovery Enablement service
Support in addressing mental health and wellbeing challenges triggered by the Covid19 pandemic

Refer to
CR-Enablement

Refer to
CR-Enablement

You can write "Prefer not to say" for any information you would rather not give.

Date of Referral *

Name of client *

Pronouns

Address *

Post Code *

Telephone/Mobile Number *

Email

Date of Birth *

Gender *

Sexuality *

Ethnicity *

Religion/Faith *

Marital Status *

Employment Status/Skills *

What is your Mental Health Condition? *

Referrer Details

Name & Address of Referrer (please specify if self-referral) *

Name of referring agency

Referrer's Phone/Mobile

Referrer's Email *

Is client aware of referral?

• Yes
• No

Reason for referral:

Please specify the impact COVID-19 has had on client's needs *

Home

Hospital, please state which one

Intermediate Care, Please state where

Managing their own home

Managing their mental health

Managing their physical health

General Confidence

Managing their money

Meeting people and doing things

Other

Physical Health Needs

Mental Health Needs

Mobility Needs

RISK, BEHAVIOUR, FRIENDS, FAMILY, PETS

GP Details

Name of GP *

Address of GP *

Telephone number of GP *

How did you hear about our service? *

Submit

Reablement Service
(Please note that this service can only accept referrals from a doctor, nurse or other professional)

Refer to Reablement

Refer to Reablement

You can write "Prefer not to say" for any information you would rather not give.

Date of Referral *

Name *

Prounouns

Address *

Telephone/Mobile Number *

Email *

Date of birth *

Gender *

Sexuality *

Ethnic background *

Religion/Faith *

Marital Status *

NHS number

Housing Status

• Sheltered Housing
• 24hr Supported
• Supported 9-5
• Council/Housing Association
• No Fixed Abode
• Temporary Accommodation

Referral details

Name & Address of referrer *

Name of referring agency

Referrer's Email *

Referrer's Phone/Mobile

Does the service user give consent for this referral to be made? *

• Yes
• No

Is the service user a carer? *

• Yes
• No

Is an interpreter needed?

• Yes
• No

If so, which language is required?

Diagnosis *

Estimated Discharge Date

Reasons for referral *

Eligibility

To meet the Reablement Service's Objective, please confirm one of the following *Support Hospital Discharge (your referral is currently being discharged from an inpatient unit, i.e. hospital, crisis house or rehab service)Admission Prevention (to help prevent an admission to hospital, crisis unit or rehab unit)Avoid Care Co-ordination (prevent referring client for care co-ordination, i.e. COAT, AOT, EIS <br> or R&R care co-ordination)Supported Housing Move-on (moving to independent living)Avoid escalation of Health and Social Care needs

Does the service user have a carer? Please provide details *

Other agencies/professionals involved

Name and role

Address

Phone

Name and role

Address

Phone

Risk Management

Submit

Psycho-Social Support Service
One-to-one interventions to address psycho-social needs

(Please note that this service can only accept referrals from a doctor, nurse or other professional)

Refer to
PSS Service

Refer to
PSS Service

You can write "Prefer not to say" for any information you would rather not give.

Date of Referral *

Name of client *

Pronouns

Address *

Post Code *

Telephone/Mobile Number *

Email

Date of Birth *

Gender *

Sexuality *

Ethnicity *

Religion/Faith *

Marital Status *

Employment Status *

What is your Mental Health Condition? *

Referrer Details

Name & Address of Referrer (please specify if self-referral) *

Name of referring agency

Referrer's Phone/Mobile

Referrer's Email *

Is client aware of referral?

• Yes
• No

Reason for referral:

Physical Health Needs

Mental Health Needs

Mobility Needs

GP Details

Name of GP *

Address of GP *

Telephone number of GP *

How did you hear about our service? *

Submit

Outcome 
Islington Mind’s LGBTQI+ specialist service, run by LGBTQI people with LGBTQI people

Refer to
Outcome

Refer to
Outcome

You can write "Prefer not to say" for any information you would rather not give.

Date of Referral *

Name of client *

Address *

Post Code *

Telephone/Mobile Number *

Email

Date of Birth *

Gender *

Pronouns

e.g. she/her, he/him, they/them

Sexuality *

Please tell us about your mental health right now

Referrer Details

Are you self-referring?

• Yes
• No

Name of referrer/referring agency

Referrer's Phone/Mobile

Referrer's Email *

If you are referring someone else, are they aware of this referral?

• Yes
• No

Reason for referral:

How did you hear about our service?

Submit

Counselling and Talking Therapies
Self-referrals only

Waiting list closed

Mother to Mother Carers Support Project
A service for mothers whose children have mental health problems

Refer to
Mother to Mother

Refer to
Mother to Mother

You can write "Prefer not to say" for any information you would rather not give.

Date of referral *

Client's Name *

Client's Telephone/Mobile

Client's Address

Client's Email *

Client's date of birth *

Are you a carer to your son/daughter?

• Yes
• No

Does your son/daughter have mental health problems?

Client's Ethnic Background *

Client's Religion/Faith *

Client's Sexual Orientation *

Have you any disabilities/health problems?

Client's Medication (if any)

Client's next of kin

Next of kin's Telephone/Mobile

Next of kin's Address

Next of kin's Email

Next of kin's relationship to client

Referrer details

Referrer's Name

Name of referring agency

Referrer's Telephone/Mobile *

Referrer's Address

Referrer's Email *

GP details

GP's name *

GP's Telephone/Mobile *

GP's Address *

GP's Email

Any other relevant information

How did you hear about our service?

Submit

Women Only space
at Ashley Road on Thursdays

Refer to
Women Only space

Refer to
Women Only space

You can write "Prefer not to say" for any information you would rather not give.

Date of Referral *

Name of client *

Pronouns

Address *

Post Code *

Telephone/Mobile Number *

Email

Date of Birth *

Gender *

Sexuality *

Ethnicity *

Religion/Faith *

Marital Status *

Employment Status *

What is your Mental Health Condition? *

Referrer Details

Name & Address of Referrer (please specify if self-referral) *

Name of referring agency

Referrer's Phone/Mobile

Referrer's Email *

Is client aware of referral?

• Yes
• No

Reason for referral:

Physical Health Needs

Mental Health Needs

Mobility Needs

GP Details

Name of GP *

Address of GP *

Telephone number of GP *

How did you hear about our service? *

Submit

Hand in Hand Peer Travel Buddy Service
If you need support in accessing appointments or activities – you will be matched with a peer who will accompany you and offer support

Refer to
Hand in Hand

Refer to
Hand in Hand

Name *

Email *

Message *

Submit