STRICTLY CONFIDENTIAL Promoting good mental health through personal development, education and employment REFERRAL TO PENTREATH Please complete this form if you wish to access our vocational services. You can find additional information on our website www.pentreath.co.uk or contact us on: 01726 862727 or info@pentreath.co.uk Please return this form to: Pentreath Ltd, St Enoder Barns, Narrow Lane, Summercourt, Newquay TR8 5EE Information About You: Full Name Date of Address Postcode Phone Landline Mobile Email Preferred Phone Letter Email Contact Initial contact will be by telephone Language If you need a translator, please state language required. NHS Gender Male / Female/ Number NI Number Please give details of your diagnosis/mental health problem: Do you have any additional needs which you feel we should know about? Please tick as many as apply to you, this will help us to identify funding to support you. On Sick Leave Less than 6 months No qualifications Employed At risk of losing Job Unemployed 6 months to 1 year Education Less than 5 GCSE’s Want to change Over 1 year More than 5 GCSE’s Never worked 2 A levels or ESA Ex-Military Single Parent Homeless Ex-offender Benefits Universal Credit Ethnicity Please tick the option which indicates your cultural background ( Prefer not to say) Income Support or Asian British Black or Black British White Other JSA Bangladeshi African British Not known Other: Indian Caribbean Gypsy Declaration Pakistani White+Asian Irish Chinese Other Other I confirm that the information on this form Other is accurate and correct. / / _ Signed Date I am willing for this information to be held by Pentreath Ltd. Pentreath is registered under the Data Protection Act. Your information will be held for auditing and funding purposes. What You Want What sort of support do you want from Pentreath? Please give details if you can.
STRICTLY CONFIDENTIAL Promoting good mental health through personal development, education and employment REFERRAL TO PENTREATH Please complete this form if you wish to access our vocational services. You can find additional information on our website www.pentreath.co.uk or contact us on: 01726 862727 or info@pentreath.co.uk Please return this form to: Pentreath Ltd, St Enoder Barns, Narrow Lane, Summercourt, Newquay TR8 5EE Information About You: Full Name Date of Address Postcode Phone Landline Mobile Email Preferred Contact Phone Letter Email Initial contact will be by telephone Language If you need a translator, please state language required. NHS Number Gender Male / Female/ NI Number Please give details of your diagnosis/mental health problem: Do you have any additional needs which you feel we should know about? Please tick as many as apply to you, this will help us to identify funding to support you. Employed On Sick Leave At risk of losing Job Want to change Unemployed Less than 6 months 6 months to 1 year Over 1 year Never worked Education No qualifications Less than 5 GCSE’s More than 5 GCSE’s 2 A levels or Benefits ESA Ex-Military Single Parent Homeless Ex-offender Universal Credit Ethnicity Please tick the option which indicates your cultural background ( Prefer not to say) Income Support or Asian British Black or Black British White Other JSA Bangladeshi African British Not known Other: Indian Caribbean Gypsy Declaration I confirm that the information on this form is accurate and correct. I am willing for this information to be held by Pentreath Ltd. Pakistani White+Asian Irish Chinese Other Other Other Signed Date / / _ Pentreath is registered under the Data Protection Act. Your information will be held for auditing and funding purposes. What You Want What sort of support do you want from Pentreath? Please give details if you can.
referral-form-2017-v2.docx