Self Referral Form - Headway Sussex

Please tick this box before proceeding with your referral form:

Please note: all Headway Sussex services accessed via this referral form are paid for services. Our support groups remain free to attend (donations welcome), and you do not need a referral form to join them.

Please indicate this type of Referral

needs Email conditions.

Date Of Referral

Your Name

Email address

Date of birth

Address

Telephone number

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

Carer Name & Contact Details (if applicable)

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

If interested in our Activity Hubs & Outreach service, please indicate how the placement will be funded?

For our Activity Hubs and Outreach service, please agree to provide verification of brain injury. Please email this to referrals@headwaysussex.org.uk.

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.