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Home > Professionals > Make a referral

Make a referral

Professional Referral Form

Referring Professional's Details

Forename *

Surname *

Job Title *

What is your organisation?

Email *

Telephone No *

Referral Notes Please enter any additional information here that may be of relevance to this referral.

I would like to refer the following client for:

Referral to Programme * If your client requires more than one form of support, additional support options will be discussed at the initial appointment. Please note that due to especially high demand for Stop Smoking Support throughout the start of 2025 our usual response times have increased. Referred individuals can expect to be contacted by a stop smoking advisor within 2-3 weeks of referral.

Sub-programme *

Location of Session *

Severe Mental Illness - Primary Care

Severe Mental Illness - Secondary Care

Severe Mental Illness - Community

Client details

Forename *

Surname *

Parent/Guardian * If applicable

Sex

Male

Female

Gender

Client Address * Please enter your postcode then click the Find button to select your address from the dropdown.

Client Address

Date of birth *

Email

Contact Number

Client's Surgery *

NHS Number

The client is 18 years or above

Is this individual working with other health or social care organisations e.g. (CAMHS) Children & Adolescent mental Health Service, Adult Mental Health Service, Outlook South West, Addaction

Access and support requirements

Physical Disability

Learning Disability

Access Support

Easy Read

Visual Support

Hearing Support

Special Disability

Client consent

I consent to my personal data and information being held within the Healthy Cornwall database *

Yes, I give permission to store and process my data

I consent to my information being processed by Healthy Cornwall for the purpose of service delivery as outlined in Healthy Cornwall's privacy policy notice: https://www.healthycornwall.org.uk/privacy-policy

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