Sutton Crisis Café: Referral form – Sutton Mental Health Foundation

Please enable JavaScript in your browser to complete this form.

Sutton Crisis Café: Referral form

(for professional 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

Please enable JavaScript in your browser to complete this form.

Client information

Full name *

First

Last

How would they like us to address them?

Gender *

Male
Female
Non-Binary
Prefer not to say

What pronouns do they use?

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 communication

Telephone
Email
Text

Telephone number *

Can we leave an answerphone message? *

Yes
No

Email address *

Referral information

Referrer name *

Referrer agency *

Referrer contact number *

Referrer 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

Someone we can contact on the client's behalf in the event of an emergency.

Does the client have an emergency contact? *

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.

Permission to provide data

I consent 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.

© Copyright 2021 Sutton Mental Health Foundation | All rights reserved | Registered Charity No. 1069945 | Registered in England No. 3549052