Refer yourself

If you would like support to get back to the things that matter to you, tell us a little about yourself. You do not need an account. A member of the team will read this and telephone you.

This form is not for emergencies. It is not monitored around the clock. If someone is at immediate risk, contact 999, NHS 111 or the local adult safeguarding team.

About you

First name *

Last name *

Date of birth

Helps us match records correctly

Postcode

Telephone number

Email address

Best way and time to make contact

For example: mornings, mobile only, needs a quiet time of day

Why this referral is being made

What has changed for you, and what would you like to be doing? *

Focus on participation: what has stopped, what they miss, what matters to them.

What support you already have

Other services, family support, groups already involved

Eligibility, as far as you know

Tick what applies. We will check these with you ourselves — leaving a box unticked will not automatically stop a referral.

They meet the service age criterionThey live in the service areaThey have a relevant health conditionThey are taking part in less than they would like toThey are able to take part by telephoneThey are not currently in crisis

Safety and consent

There is a safety concern the team should know aboutTick this only to flag a concern for review. It does not raise an alert — use the emergency routes above if someone is at immediate risk.

Mind & Motion Community Connect will use this information to consider the referral and, if it is accepted, to provide the service. It is stored securely, seen only by authorised staff, and never used for anything else without a lawful basis. Full consent is discussed and recorded with you at first contact.

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