Jami referral information

Please complete the form below

Please complete the data/confidentiality section below to enable us to process your referral. Without this consent we are unable to process your referral to our services.

"*" indicates required fields

Your consent

Why we need data, how we store it and what we do with it?
We require information to fully understand your situation, to enable us to best understand whether we can support you and to signpost you to other organisations with your consent, if necessary. We store your data on our secure and confidential database which will only be accessed by colleagues within Jami who are involved in supporting you. We use the data on our system to create reports, but these are confidential and anonymous and will not be attributed to you.

Do you consent to this*

Yes

Confidentiality
Your personal information is confidential within Jami and we will always ask for your consent to share this with those who may request it outside of Jami. We will not share your data with others outside of our organisation without your consent. However, we do exercise the right to break confidentiality in a circumstance where we may be concerned for your safety or the safety of others.

Do you consent to this*

Yes

Your information

Name*

Date of Birth*

Gender*

Male

Female

Other

Home address*

Do you have a fixed address?*

Yes

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*

Jami is a Jewish Mental Health charity, do you identify as Jewish?*

Yes

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 [email protected] to do so.

Are you happy to continue with these questions?*

Yes, I understand the information provided and I give my consent to Jami to process the information collected in this form for equality and diversity purposes

Please ask another time

How would you describe your ethnicity?

Which of the following options best describes your sexual orientation?

Straight/heterosexual

Gay or Lesbian

Other/would prefer to self-describe

Prefer not to say

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

Is your gender identity the same as the sex you were assigned at birth?

Yes (a person who was born male and identifies as a man, or a person who was born female and identifies as a woman)

Prefer not to say

If no, please write in gender identity

Which pronouns would you like us to use for you?

He/him/his

She/her/hers

They/them/theirs

Other

Prefer not to say

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)

Do you have any physical conditions or illness that we should know about?*

Yes

Prefer not to say

If yes, what are they?

Does this impact on your day-to-day life?*

Yes, a lot

Yes, a little

Not at all

Prefer not to say

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?

Occasionally we send out updates on our core services, surveys to gather feedback on how to improve our support, information on how you can get involved at Jami, and anything else that we think would be useful for you (beyond your direct support plan). Please let me know if you would like to opt out of receiving these. You can amend your preference later should you change your mind

Opt out

Jami’s Head Room Café runs a programme of groups and events that offer mutual support and open conversations about mental health. These are free and open to people from all religions or non, and a diversity of mental health experiences. Would you like to receive more information from the Café team?

Yes

As a Jami service user, you can access the Jami’s education service, which offers a programme of mental health courses and events. These will help support you or those you care for to develop your knowledge and skills. Would you like to receive information about these courses directly from the Jami education team?

Yes

Are you happy to provide feedback on the service you’ve received so far? If so, how would you like to give the feedback? This is so that we can improve the service for others like yourself and gather evidence for how the service may be doing well

Phone call

Survey sent by text message

Survey sent by email