St Charles Hospital Re-Referral Submission Form — Citizens Advice Kensington and Chelsea

Re-referrals for St Charles Mental Health Unit clients with existing issues

Please complete our referral form below only if our advice session supervisor has asked you to do so.

This is a shorter form, so you don’t have to re-enter all of the client’s data, that is used to ensure we can allocate the time needed to certain clients that need another appointment with us on an existing issue. Please note that a further appointment will be counted towards our total number of referrals we can for the week.

We are able to take six referrals each week. Please send those referrals by midday on Thursdays so that we can process the referral for the following week. You will receive email confirmation of a referral once you submit this form.

REFERRAL DETAILS

Referrer's Full Name

First Name

Last Name

Referrer's Email

Referrer's Phone Number

(###)

###

####

Referrer's Role

What is your role in relation to the client?

CLIENT CONTACT DETAILS

Client's Full Name

First Name

Last Name

Client's Date of Birth

MM

DD

YYYY

REFERRAL ISSUE(S)

Issue requiring second appointment

Please briefly outline the issue that requires a further appointment.