BSW (BaNES) Access Referral Form test Title Name * Name First Name First Name Last Name Last Name Do you use any other names? Please write other names here Date of birth * Address * Postcode * Phone number Ok to leave voicemail? Yes No Ok to send SMS text? Yes No Email * How would you prefer we contact you? * PhoneEmailEither Pronouns He/himShe/herThey/themPrefer not to sayOther (please specify) Pronouns Do you have any support needs with written or spoken communication? E.g. Large print, English as a second language, hearing or speech need. * Yes No If yes, please give details GP Details GP Surgery * Name of GP NHS number (if known) GP email GP phone number Are you getting in touch for yourself or someone else? * Myself Someone else If someone else, please complete your organisation/service details: Service name Service phone Service email If you are getting in touch for someone else, please share details of any additional documentation that you have agreement to share, e.g. up to date risk information: Please list your documentation here. A Practitioner will contact you regarding additional documentation. About you This section allows you to tell us about why and how you feel you would like our support, so we know how to best help you. Please give as much detail as you feel is appropriate, including if you have been given a mental health diagnosis, and whether you agree with this diagnosis. What type of support would you like to receive? * Emergency contact details Name of emergency contact Relationship to you Their phone number Their email Confidentiality and data protection Protecting your personal information is very important to the Mental Health and Wellbeing Partnership and we will ensure your personal data is kept confidential and held securely. If you are in Swindon or BANES, your information will be stored by Second Step. If you are in Wiltshire your information will be stored by Alabaré. Second Step We use a great deal of information in our services. For example, we process information about current and past service users working with us or receiving support or tenants in our accommodation. For each service Privacy Notices will be presented directly to these individuals in an upfront way, to ensure they clearly understand how we will use their information. To find out how we use, store and protect information obtained for these purposes please read our protecting your personal information leaflet (this is Second Step’s Privacy Notice and is available on the website or in hard copy) If you would like to ask questions about how your information is used, or raise a concern you can contact DPO@second-step.co.uk Alabaré Alabaré is registered as a Data Controller with the Information Commissioner’s Office (ICO). We are committed to protecting your personal information and to being transparent about what information, we hold. Alabaré understands its obligations to you to help you understand how and why we process your personal data. Our Privacy Notice tells you about these uses. The Data Protection Act 2018 and the EU General Data Protection Regulation 2016/679 (the GDPR”) govern our Data Protection Policy and Procedures. To find out how we use, store and protect information obtained for these purposes please read our Privacy Notice. If you have any questions or concerns about our use of your personal information please email the Alabaré Data Protection Lead enquiries@alabare.co.uk. Declaration I declare that the information provided by me is accurate to the best of my knowledge. If I choose to go ahead and receive support through this service, I hereby authorise Second Step and/or Alabaré to store and process personal information related to me and the service I receive, as described in their Privacy Notices. By submitting this request for support you are agreeing to the statement above. * I understand Submit If you are human, leave this field blank.
