referral information form

You can learn more about how we handle your personal data and your rights by reviewing our Privacy notice.
Please be aware that if we need information outside our organisation, we may ask for your consent. However, we may share information without your consent where we are obliged to by law or for safeguarding reasons.

Your information

Date of Birth*

Mobile number*

Email address*

GP’s name & address*

Please let us know who we should contact if an emergency were to arise

Contact name*

Relationship to you*

Contact number*

If other/would prefer to self-describe, please add here:

How did you hear about us?

Reason for contacting us/ what support do you feel you need?

Background history

Please tell us a little bit about yourself and if you have had any previous support with your mental health?

Current situation

What difficulties are you experiencing? Are you living alone or with family/children? Are you working/volunteering?

Mental health, difficulties and how they impact on your life

Are you currently in contact with any mental health professionals or services? Are there any triggers (things that really upset you) or early warning signs (things that you would tell staff that you are becoming unwell) that you know of? Do you currently take any medication?

Do you have a mental health diagnosis?

(Please note no formal diagnosis is necessary for you to access Jami services)

If yes, a little - how does this impact you?

Current support networks

What support networks do you have e.g. friends, family, synagogue? What do you / did you enjoy doing/hobbies? What keeps you well?

Safeguarding issues

Do you have thoughts around harming yourself or experience suicidal thoughts? Are you at risk of abuse?

Jami strives to deliver services that value diversity, respond to people’s unique backgrounds and characteristics, and challenge discrimination of any form. We would like to ask you a few questions to allow us to provide a more accessible and inclusive service. These questions are voluntary and will in no way affect whether you are eligible to receive our services.

If you decide to complete the questions you give us your consent to process your information, you are entitled to withdraw your consent and request that we delete your data at any time. Please email info@jamiuk.org to do so.

How would you describe your ethnicity?

If other/would prefer to self-describe, please add here:

If no, please write in gender identity

If yes, what are they?

Jami runs a community programme of groups and events at Head Room café and online that offer mutual support and open conversations on mental health visit here for more information on these groups.

As a service user, you can also access our programme of mental health courses and events to help you or those you care for develop your knowledge and skills. You can find out more here.

Jami referral information

Please complete the form below - without your information we are unable to process your referral to our service.

Your information

Next Steps: Sync an Email Add-On

Jami referral information

Please complete the form below - without your information we are unable to process your referral to our service.

Your information

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Next Steps: Sync an Email Add-On