CHESS referral form

Welcome!

Below is the referral form for CHESS

CHESS, which stands for Crisis help; emotional &social support, is designed to be a safe, open space for anyone in Bassetlaw over the age of 18, at risk of suicide.

The sessions are hosted via zoom and include a mixture of group activities with opportunity to have 1-1 time with a trained clinical support worker.

Question Title

* 1. Referral date

Date / Time

Date

Time

AM/PM

Question Title

* 2. Is this an agency referral?

Ambulance service

Police

111

Crisis Team

Local mental health team

Primary care (IAPT)

Education setting

Third sector service

Other NHS

No, this is a self referral

Other (please specify)

Question Title

* 3. Name and contact details of referrer

Name

Company

Address

Address 2

City/Town

State/Province

ZIP/Postal Code

Email Address

Phone Number

Question Title

* 4. Personal details of the person needing support

Name *

Address *

Address 2

City/Town *

ZIP/Postal Code *

Email Address *

Phone Number *

Question Title

* 5. Is the person at their place of residence at present?

Yes

If not please specify the address where they will be when we make contact with them?

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* 6. Date of Birth of person needing support

Date

Question Title

* 7. Gender

Male

Female

Other (please specify)

Question Title

* 8. Ethnicity

White

Mixed / Dual Background

Asian or Asian British

Black or Black British

Chinese

Any Other Ethnic Group

Question Title

* 9. Next of kin details

Name *

Address *

Address 2

City/Town *

State/Province

ZIP/Postal Code *

Phone Number *

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* 10. Do we have permission to make contact with them? **We will only breach confidentiality without your consent if there is imminent risk to you or someone else. For more details, please ask.

Yes

If there are any circumstances that you don't want this please specify

Question Title

* 11. Has the person needing support been using alcohol/substances in the last three hours?

Yes

If yes please specify

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* 12. Does the person needing support have any history of violence towards others?

Yes

If yes, please provide details:

Question Title

* 13. What is your preferred time to attend the session? (please note, we will try to accommodate your preferred time slot but this may not always be possible)

Wednesday at 14.00

Wednesday at 14.20

Wednesday at 14.40

Wednesday at 15.00

Wednesday at 15.20

Wednesday at 15.40

Wednesday at 16.00

Other (please specify)

Question Title

* 14. Has the person needing support used CHESS before?

Yes

If so (please specify which)

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* 15. CHESS sessions are hosted on zoom, do you require assistance with accessing zoom?

Yes

Thank you for completing the referral form.

The team will be in contact with you soon. Occasionally, our emails may go into your junk mail box so please keep an eye out. If you have not heard from us, please drop us an email at crisis@tomorrowproject.org.uk

We look forward to supporting you.

If you need support between now and then, below are some services that you can use:

For listening support, Samaritans are available 24/7 on 116 123
For text support, Shout are available 24/7 on 85258
In an emergency, please contact the emergency services on 999