Self Referral Form - Headway Sussex

Date Of Referral

Your Name

Email address

Carer Name & Contact Details (if applicable)

Date of birth

Telephone number

are other prominent

Details and effects of your Brain Injury & any other medical conditions. (Please note that the brain injury must be the prominent factor and reason for referral).

Mental Health and Wellbeing/ Diagnosed mental health conditions

Potential risks related to home visits e.g. history of domestic violence, pets, state of home

Transport needs (Please note HSX are not responsible for arranging transport)

Any other information which may be relevant

GP Name & Contact Details

Name & contact details for any other professional or specialist involved (Social Worker / Physio / SALT / OT/Community Rehab Team / Community Nurse)

Please indicate which services you are interested in:

Consent

This information is correct to the best of my knowledge
By submitting this form, you confirm that you have given consent for your personal data to be stored and processed by Headway Sussex in accordance with our Privacy Policy.
This information will be securely stored and used to contact you. To help Headway Sussex support you more effectively, we may need to share information with and receive information from other parties involved in your support.
All information will be kept strictly confidential and will only be accessible to staff on a need-to-know basis.