Sutton Crisis Café: Carers referral form – Sutton Mental Health Foundation

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Sutton Crisis Café: Carers referral form

(for carers use only) 0800 012 9082

crisiscafe@smhf.org.uk

suttoncrisiscafe.org.uk

6:30pm to 11pm (last admission 10:30pm), 7 days a week, 365 days a year

63 Downs Road, Belmont, Sutton, Surrey SM2 5NR

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Name of person in crisis who you support

Full name *

First

Last

How would they like us to address them?

Gender *

Male
Female
Non-Binary
Prefer not to say

What are their pronouns?

He/Him
She/Her
They/Them
Other

Pronouns

Ethnic group? *

White
MIxed/multiple ethnic groups
Asian/Asian British
Black African/Caribbean/Black British
Other ethnic group
Prefer not to say

Date of birth *

Please note: We only accept referrals for those aged 18 or above.

NHS number (if known)

Address *

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

How may we contact them? *

Telephone
Email
Text

Please select all that we can use

Preferred method of contact

Telephone
Email
Text

Please select all that we can use

Telephone number *

Can we leave an answerphone message? *

Yes
No

Email address *

Referral information

Carers name *

Care agency

Carers contact number *

Carers email address

Reason(s) for referral: *

Do you feel they are a risk to themselves?

No
Yes - low risk
Yes - medium risk

Risk to themselves

Do you feel they are a risk to others?

No
Yes - low risk
Yes - medium risk

Risk to others

Do you feel they are at risk from others?

No
Yes - low risk
Yes - medium risk

At risk from others

Is there anything else we should know about?

Special requirements
Triggers
Health issues
Disabilities

Anything else we should know about?

Other helpful information

Have they visited Sutton Crisis Café in the past? *

Yes
No

Are they known to any other mental health services?

Yes - currently
Yes - in the past
No

Do they require an interpreter? *

Yes
No

In which language? *

Emergency contact information

Are you the person we should contact in an emergency? *

Yes
No

Emergency contact name *

Emergency contact number *

Relationship to client

GDPR Agreement *

I understand that SMHF/this website will store the submitted information so that Sutton Crisis Cafe can respond to this enquiry.

}ermission to provide data *

I confirm that the client has given permission to provide their personal details

By submitting this form the client consents to their demographic information (age, gender, ethnic group & local authority) being shared in an anonymised form for monitoring purposes.

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