Please note that all fields are mandatory, and we require all the below information to process the referral.
Consent
IMPORTANT: Before you fill out this form, please confirm you have gained the following consents from the veteran.
Without their consent, we will be unable to progress their referral.
Is the veteran aware and has given consent for the referral to be made?
* Required
Yes
No
Veteran consented to referral being sent to Midlands Op COURAGE Hub, meaning all the information in this referral being shared with the appropriate teams:
Lincolnshire Partnership NHS Foundation Trust Coventry and Warwickshire Partnership NHS Trust Birmingham and Solihull Mental Health NHS Foundation Trust
Does veteran consent to the above?
* Required
Yes
No
Veteran consented to referral information being shared by the receiving organisation with other agencies involved in the assessment process as appropriate.
They understand that they will handle all information in line with Data Protection Legislation and their own Confidentiality and Information Governance Protocols.
Does veteran consent to the above?
* Required
Yes
No
Date consent obtained
* Required
Veteran details
Name of veteran
* Required
Date of birth
* Required
Age
* Required
Ethnicity
* Required
Gender
* Required
Served in
* Required
Army
Royal Navy
Royal Air Force
Royal Marines
Merchant Navy
Any other relevant information?
Service number
* Required
Date joined
* Required
Date of discharge
* Required
Length of service
* Required
Veteran contact details
Address
* Required
Home phone number
Mobile
* Required
Work/other
Email address
Consent to leave messages?
* Required
Yes
No
Any communication difficulties or considerations?
GP details
Named GP
* Required
Surgery address
* Required
Phone
* Required
Email (if known)
Emergency contact details
If there are no emergency contact details, please type 'none' into the boxes.
Name of emergency contact
* Required
Relationship
* Required
Phone number
* Required
Consent to contact
* Required
Yes
No
Level of information
Referrer's details
Name of referrer
* Required
Role
Organisation
* Required
Contact number
* Required
Contact email
* Required
Referral details
Is the veteran receiving any support from other agencies currently?
* Required
Yes
No
If yes, please give brief outline including dates and intervention
Has the veteran received support from Op COURAGE services previously (TILS/HIS/CTS)?
* Required
Yes
No
How did you hear about Op COURAGE services?
* Required
Mental health needs
* Required
Physical health needs
* Required
Any identified social needs
Reason for referral. With consideration of all the above information: What are the main impacts on the veteran’s life? What does the veteran feel they need help with?
* Required
Risk to self?
* Required
Yes
No
If yes, please give brief further details
Risk to others?
* Required
Yes
No
If yes, please give brief further details
Risk from others?
* Required
Yes
No
If yes, please give brief further details
Any current forensic convictions/ restrictions in place?
* Required
Yes
No
If yes, please give details
Any current involvement with police or probation?
* Required
Yes
No
If yes, please give names and contact details
Does the veteran have any current involvement with safeguarding?
* Required
Yes
No
If yes, please give names and contact details
