Referral form on behalf of Veteran

Before completing this referral on behalf of someone else, please confirm that they are:
- A veteran (regular, reserve or national service) of the UK Armed Forces
- Registered with a GP in Wales (if moving to Wales, you will be required to register with a GP in Wales at the earliest opportunity)
- Have a military service-related or suspected military service-related mental health condition.
- All fields with a * will need you to add some text i.e. NA if you are unable to answer that question.

Referrer Details

Name of referrer(*)

Invalid Input

Please tick here if you are the Veterans Doctor

Yes Invalid Input

Organisation name or relationship to veteran(*)

Invalid Input

Referrer Address(*)

Invalid Input

Referrer Contact Number(*)

Invalid Input

Has the veteran consented to the referral(*)

Yes No Invalid Input

Does the veteran have any communication - mobility- disability issues(*)

Yes No Invalid Input

If yes please expand

Invalid Input

Veterans Details

Name(*)

Invalid Input

DOB(*)

Invalid Input

Gender(*)

Invalid Input

Language Preference

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Address(*)

Invalid Input

Landline or Mobile Number(*)

Invalid Input

Permission to contact

Yes No Invalid Input

Permission to leave a voicemail(*)

YesNo Invalid Input

Permission to text

YesNo Invalid Input

Email(*)

Invalid Input

Permission to Email(*)

Yes No Invalid Input

Military Service Details

Service Number(*)

Invalid Input

Branch of Armed Services - Select all that apply

Join Date(*)

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Leave Date(*)

Invalid Input

Deployed operationally

Yes No Invalid Input

If yes, please list location/s and date/s

Location

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Date

Invalid Input

Do you need more locations/dates?

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Location 2

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Date 2

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Location 3

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Date 3

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Location 4

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Date 4

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Location 5

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Date 5

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Location 6

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Date 6

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Location 7

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Date 7

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Location 8

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Date 8

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Location 9

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Date 9

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Next of Kin Details

Next of Kin Name(*)

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Relationship to Veteran(*)

Invalid Input

Next of Kin Address

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Contact Number(*)

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Does the Veteran have any children(*)

Yes No Invalid Input

If yes does the child or children live with the veteran

Yes No Invalid Input

Child Name

Invalid Input

Child D.O.B

Invalid Input

Child relationship to Veteran

Invalid Input

Do you need to add more children?

Invalid Input

2nd Childs Name

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2nd Childs D.O.B

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2nd Childs Relationship to Veteran

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3rd Childs Name

Invalid Input

3rd Childs D.O.B

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3rd Childs Relationship to Veteran

Invalid Input

4th Childs Name

Invalid Input

4th Childs D.O.B

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4th Childs Relationship to Veteran

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5th Childs Name

Invalid Input

5th Childs D.O.B

Invalid Input

5th Childs Relationship to Veteran

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Are there any child protection or child in need issues or concerns

Yes No Invalid Input

If yes please outline the steps you have taken to promote the safety of the child or children

Invalid Input

GP Details

GP Name

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GP Surgery(*)

Invalid Input

GP Address(*)

Invalid Input

GP Contact Number(*)

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Consent for VNHSW to correspond with GP

YesNo Invalid Input

Reason for Referral

Please tell us about the Veterans mental health difficulties and how these are related to their military service(*)

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Please tell us about the Veterans current alcohol or drug misuse(*)

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Risk Issues – Self:

Are they at risk of causing harm to themself(*)

YesNo Invalid Input

If yes please provide details

Invalid Input

Risk Issues – Others:

Are they at risk of causing harm to others(*)

YesNo Invalid Input

If yes please provide details

Invalid Input

Please be aware that Veterans’ NHS Wales is unable to respond to veterans who need urgent or emergency mental health care. Individuals in crisis or requiring urgent assistance should seek help from their GP or out of hours service. Alternatively, C.A.L.L. is a 24/7 mental health helpline for Wales and it offers a confidential listening and support service. Phone 0800 132 737 or Text ‘Help’ to 81066.

Previous mental health difficulties(*)

YesNo Invalid Input

If yes please provide details including any previous mental health treatment or support

Invalid Input

Current Medication(*)

YesNo Invalid Input

If yes please provide further details (*)

Invalid Input

Are any other services involved in supporting the Veteran(*)

Yes No Invalid Input

If yes please advise name - designation and contact number

Invalid Input

Consent for VNHSW to contact the named person

YesNo Invalid Input

Recaptcha(*)

Invalid Input

Online Referral Behalf of Veteran