Community & Culture Archives - Penumbra Mental Health

Penumbra is a charity (SC 010387) and a company limited by guarantee (SC 091542) registered in Scotland.

Registered Office: Orchard Brae House, 30 Queensferry Road, Edinburgh, EH4 2HS, 0131 475 2380

If you are completing a self-referral, complete all of section A and then click next to submit the form.

If you are referring someone for support, please complete sections A and B.

Welcome to our online self-referral form. Please complete as much of this form as possible. Once we receive your form, we aim to respond within 72 hours. Thank you.

Do you live in East Renfrewshire ?

Yes No

Are you aged between 18 and 65 years?

Yes No

Do you currently use a mental health service in East Renfrewshire?

Yes No

If yes, which service(s) do you use?

How did you hear about East Ren Peer service?

Have you use the East Ren Peer service before?

If yes, please tell us when you used the East Ren Peer service:

Please tell us your preferred method of contact:

Text Email Voicemail Any

Do you identify as disabled?

Yes No

Next of kin (if applicable):

GP name and contact:

Do you have concerns about your personal health and safety?

Yes No

If yes, please tell us why: (choose as many options as you feel apply to you

Can you tell us if you have any convictions spent, current or pending?

Please tell us if you have a history of violence or aggression:

Do you have any long term health conditions such as blood borne illnesses?

Do you have a history of inappropriate behaviour (ie sexual disinhibition or anti social behaviour)?

Tell us the reason for your contact, ie, what would you like to get out of the next six months of support, any outcomes or goals?

We want to let you know that a copy of this form will be kept. The law states that your personal information must be held in confidence unless under exceptional circumstances such as protecting someone from harm. We will securely store a copy of this form and retain it according to our data protection policies - copy of which will be available to you on request. To help ensure that you receive the support best suited to your needs, this information may be shared with other agencies and persons, but only with your agreed consent.

I consent to Penumbra retaining a record of my information I consent to my information being shared with other agencies associated with my support

Please complete Section A (details of the person you are referring) and Section B (your own details as the referrer).

Once we have your form, our team will aim to contact the person you’re referring within 72 hours. Thank you.

SECTION A (the person you are referring): Firstname

Surname

Address

Postcode

Date of Birth

Phone number

We'll normally contact the person by telephone. Let us know if they have a preferred method of contact:

Text Email Voicemail

What challenges is the person facing just now?

What do you think would help to improve the person's wellbeing?

Which of the following options are most suited to the person?

Wellbeing Workshop Peer Support Tools & techniques that promote wellbeing Work or volunteering opportunities Community Activities (e.g. gardening, arts & crafts, gym, walking etc) Addressing practical barriers (e.g. travel confidence, community participation)

Do you have concerns about the person's safety? (please choose one)

Any additional comments

Do you have concerns for the safety of others? (please choose one)

Any additional comments

Is there anything else you would like to tell us about the person that you think would be useful for us to know?

Referrer's Firstname

Referrer's Surname

Referrer's Address

Referrer's Postcode

Referrer's Phone Number

Referrer's Email

Please add any supporting information and detail any risk to lone working that we should be aware of

Date

How can we help you?

Thank you for considering leaving a gift in your Will.

To receive further information about the process and to find out how your gift could be used, please complete and return the form below. Thank you.

Please give us as much information as you can. Once we have your form, our team will aim to contact you within 72 hours. Thank you.

SECTION A: Firstname

Surname

Address

Postcode

Date of Birth

Phone number

We'll normally contact you by telephone. Let us know if you have a preferred method of contact:

Text Email Voicemail

What do you feel are the main challenges you face right now?

What do you think would help to improve your wellbeing?

Which of the following options are most suited to you?

Do you have concerns about your personal safety? (please choose one)

Any additional comments

Do you have concerns for the safety of others? (please choose one)

Any additional comments

Is there anything else you would like to tell us about yourself that you think would be useful for us to know?

Date

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Courage

We will do the right thing. Standing up for people, their rights, wellbeing and recovery

Compassion

We listen and respond with hope, kindness and respect.

Curiosity

We explore, reflect, learn and adapt to create solutions that are best for people’s wellbeing.

Collaboration

We will work with those who share our vision and values.

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Event category: Community & Culture

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How can we help you?

Courage

Compassion

Curiosity

Collaboration

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