Veteran Referral Form - Veterans Wales

Before completing this referral, please confirm that you are:
- A veteran (regular, reserve or national service) of the UK Armed Forces
- Resident in Wales (or moving to Wales following discharge from the 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.

Veterans Details

Name(*)

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DOB(*)

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Gender(*)

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Language Preference

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Address(*)

Invalid Input

Landline or Mobile Number(*)

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Permission to contact

Yes No Invalid Input

Permission to leave a voicemail(*)

YesNo Invalid Input

Permission to text

YesNo Invalid Input

Email(*)

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Permission to Email(*)

Yes No Invalid Input

Military Service Details

Service Number(*)

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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

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Need More Locations/date Fields?

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Location 2

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Dates 2

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Location 3

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Dates 3

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Location 4

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Dates 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 you(*)

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Contact Number(*)

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Next of Kin Address

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Do you have any children(*)

Yes No Invalid Input

Child Name

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Child D.O.B

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Child relationship to you

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Do you need too add more children?

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2nd Childs Name

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2nd Child D.O.B

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2nd child relationship to you

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3rd child name

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3rd child D.O.B

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3rd child relationship to you

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4th child name

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4th child D.O.B

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4th child relationship to you

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5th child name

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5th child D.O.B

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5th child relationship to you

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Do you have any children who live with you either some or all of the time

Yes No Invalid Input

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

Yes No Invalid Input

If yes please provide details of any services involved

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GP Details

GP Name

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GP Surgery(*)

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GP Address(*)

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GP Contact Number(*)

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Consent for VNHSW to correspond with GP

YesNo Invalid Input

Reason for Referral

Please tell us about your mental health difficulties and how you think these are related to your military service(*)

Invalid Input

Please tell us about your current alcohol or drug use(*)

Invalid Input

Risk Issues – Others:

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

YesNo Invalid Input

If yes please provide details

Invalid Input

Risk Issues – Self:

Are you at risk of causing harm to yourself(*)

YesNo Invalid Input

If yes please provide details

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Veterans’ NHS Wales is an out-patient service. If you require urgent or emergency mental healthcare because you are in crisis, we recommend that you seek help immediately from your GP, out of hours service or your local Accident and Emergency Unit where there is a Psychiatrist on call. Alternatively, C.A.L.L. is a 24/7/365 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

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Are you taking any prescribed medication currently(*)

YesNo Invalid Input

If yes please provide further details (*)

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Are any other services involved in supporting you currently(*)

Yes No Invalid Input

If yes please provide their name - designation and contact number

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Do you have any communication - mobility- disability issues(*)

YesNo Invalid Input

If yes please specify

Invalid Input

Consent for VNHSW to contact the named person

YesNo Invalid Input

Recaptcha(*)

Invalid Input

Online Referral Veteran