Lamplight API response

First name

Last name

Address 1

Address 2

Address 5

Postcode

Email address

Mobile phone

Phone number

Tick ALL boxes to confirm we can contact you regarding our service otherwise we will be unable to progress the referral

By post

By email

By mobile

By text message

Other information

Date of birth

Gender

Ethnic Group

Currently using any of the following mental health services

Currently under a section of Mental Health Act or Community Treatment Order (CTO)

Ever been in hospital under Section 3, 37, 45A, 47 or 49 of the Mental Health Act

Are you currently in Education / Training

Are you currently Working

Receiving any of the following benefits

Eligible for Free or Subsidised Travel on Public Transport

Care Coordinator?

Care Coordinator First Name

Care Coordinator Last Name

Care Coordinator Service Type

If other Service Type, please specify

Care Coordinator Email Address

Care Coordinator Mobile Phone Number

Care Coordinator Landline Phone Number

Is this referral being made by Care Coordinator?

First Name of Person making Referral (if different to Care Coordinator)

Last Name of Person making Referral (if different to Care Coordinator)

Job Title /Professional Role of person making referral

Email of person making referral

Mobile Phone number of person making referral

Landline Phone number of person making referral

Service Type of person making referral

Does client have any risk?

Are you living in supported accomodation

Are you currently currently inpatient / in hospital

Please confirm the following criteria applies to this referral

The client is NOT subject to Section 117 of Mental Health Act (and not eligible for social care funding). Referred by Care Coordinator or health or social care worker. (FURTHER PROOF MAY BE REQUIRED)

Please confirm for the 12-WEEK PROGRAMME the following criteria applies to this referral (Clinical) - Cost: £65 per week:

The client is subject to Section 117 of Mental Health Act (or otherwise eligible for social care funding). Referred by Care Coordinator or health or social care worker. CHOOSE TO CONFIRM PAYMENT BY LOCAL AUTHORITY / CCG

KEY CHANGES REFERRAL FORM

Other information