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SMHF self-referral form
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Contact details
Full name
*
First
Last
How would you like us to address you?
What pronouns do you use?
*
He/Him
She/Her
They/Them
Other
Other (please specify)
*
How may we contact you?
*
Telephone
Text
Email
Please select all that we can use
Mobile number
Landline number
Can we leave an answerphone message?
*
Yes
No
Email address
Would you like to subscribe to our mailing list?
Yes - email address required
No
Preferred method of contact
Telephone
Text
Email
Do you require an interpreter?
*
Yes
No
In which language?
Any other specific contact instructions?
Personal details
Address
*
Address Line 1
Address Line 2
City
State / Province / Region
Postal Code
Do you live within the London Borough of Sutton?
*
Yes
No
I'm not sure
Which local authority do you live in?
Date of Birth
*
DD
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MM
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YYYY
2026
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1931
1930
1929
1928
1927
1926
1925
1924
1923
1922
1921
1920
Please note: We only accept referrals for those aged 18 or above.
Gender
*
Male
Female
Non-binary
Prefer not to say
Ethnic group?
*
White
Mixed/multiple ethnic groups
Asian/Asian British
Black African/Caribbean/Black British
Other ethnic group
Prefer not to say
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Emergency contact information
Someone we can contact on your behalf in the event of an emergency.
Do you have an emergency contact?
*
Yes
No
Emergency contact name
*
Emergency contact number
*
Relationship to you
How can we help you?
What are your support needs?
*
Mental health
Emotional wellbeing
Control of daily life
Work, education & training
Recreation & socialising
Physical health
Budgeting & Money
Networks of support
Keeping safe
Self-confidence
Other
Is there anything else we should know about?
Special requirements
Triggers
Health issues
Disabilities
Please select all that apply
Further details
Any further comments?
Which services are you interested in?
*
Belmont Connect
Intentional Peer Support
Due to current capacity we have a waiting list for Intentional Peer Support.
Other useful information
How did you hear about us?
*
Select
E-news
Leaflet or poster
Professional (e.g. GP or CMHT)
Social media
Internet
Other
GDPR Agreement
*
I understand that Sutton Mental Health Foundation will store the submitted information for the purposes of responding to this enquiry.
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