Referral : Welcome

PLEASE NOTE: The Peer Support service helps people to feel confident in managing their own health and care. This happens when people with similar long-term conditions, or health experiences, come together to support each other - either on a one-to-one or group basis. It is enabled through relationships that build mutual acceptance and understanding. PCP leads the delivery of Peer Support in the community, within a county wide system. We work with Tees, Esk and Wear Valleys NHS Foundation Trust and voluntary sector partners to provide a team of Peer Support Workers for local people. These workers share their lived experience and provide one-to-one support and groups in the community. Our service offers peer support from those who have lived experience of mental health difficulties to build confidence and improve mental health in the local community. We support adults who live or work in County Durham. We understand you may have limited information at this stage but ask that you confirm consent, provide contact details for yourself and the person coming into the service. You will need to complete all mandatory fields (marked with an *) before your form will be accepted. We welcome any additional information you are able to provide alongside this but appreciate this may not always be possible. We require consent of the person coming into the service to store and share their personal information with relevant partners. We will store the information on this form securely and safely and will share it with Tees, Esk and Wear Valley NHS Foundation Trust and other voluntary organisations who make up this multidisciplinary service. We may also share personal information with other NHS and charity organisations to provide further support to the service user.

Please click here for Privacy Statement information - to read details of how our service collects, holds and uses information in accordance with the Data Protection Act.

Consent to record information *

Yes

Any client who comes into the service who develops symptoms of COVID-19 should inform us of this at the point of joining us, first contact and/or prior to any face-to-face contact.

* For someone coming to the service direct themselves, please tick to select you are consenting for us to contact

I confirm the client has given consent for the Peer Support team to contact them using the details provided on this form.* *

Yes

Please select which organisation, service or person is providing the client details: *

Contacts Job Role *

NHS No

First name *

Last name *

Address *

Letter allowed? *

Yes

Postcode *

Tel *

Mobile

SMS allowed?

Yes

Email allowed

Yes

Please tell us what you/ the person coming into the service would like support with *

GP registered *

Unregistered

Registered

GP Details *

Emergency contact: Relationship to client

Emergency contact: Name

Emergency contact: Tel

Gender *

Male

Female

Prefer not to say

Prefer to self identify - please state in notes

DOB

Age Band

Ethnic Group

Religion or belief

Which of the following options describes your sexual orientation?

Straight or Heterosexual

Gay or Lesbian

Bisexual

Other

Prefer not to say

Does you gender identify match your sex registered at birth?

Yes

Prefer not to say

Language support needed

Yes

If yes, what language

Interpreter required?

No - Interpreter not required

No - Interpreter was required but did not attend

Yes - Another Person

Yes - Family member or friend

Yes - Professional Interpreter

The Equality Act 2010 defines a disabled person as "someone who has a physical or mental impairment that has a substantial and long-term adverse effect on their ability to carry out normal day to day activities."

Do you consider yourself to have a disability according to the terms given in the Equality Act?

Yes

If yes, please tick all that apply...

Which statement best describes your economic activity?

Main Employment Status

Benefit Claimant

Yes

Not Stated

Unknown

If you are employed, do you work in County Durham

Yes

Prefer not to say

Not applicable

Are you an unpaid carer?

Yes

Carer / Advocate: The patient has confirmed the following person (s) should be included in correspondence (* Please include carer / advocates name and contact number)

Are you a veteran?

Yes

Contact details of the person sending the client to the service

Name *

Mobile *

Email *

Any other relevant information you would like to share

For example, details around why the person is coming into the service, specific support needs, background information, useful information for arranging sessions etc.
If there are several aspects of need please state if signposting / transfer to other services have been done already and if any other support is being provided.
Is there any risk to self and/or any risk to others?
Have you ever had or currently going through any criminal investigations?
Note: Risk does not necessarily exclude people from our service however there needs to be plans to support the client to manage their risk safely with involvement of other appropriate services to work alongside our work

Any other information? *

None

For Information Only

Minor Risk/ Alert

Risk/ Alert

Serious Risk/ Alert

Notes *

Access to Service Form