Refer Someone Else - Veterans Wales

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

Invalid Input

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(*)

Invalid Input

Leave Date(*)

Invalid Input

Deployed operationally

Yes No Invalid Input

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

Location

Invalid Input

Date

Invalid Input

Do you need more locations/dates?

Invalid Input

Location 2

Invalid Input

Date 2

Invalid Input

Location 3

Invalid Input

Date 3

Invalid Input

Location 4

Invalid Input

Date 4

Invalid Input

Location 5

Invalid Input

Date 5

Invalid Input

Location 6

Invalid Input

Date 6

Invalid Input

Location 7

Invalid Input

Date 7

Invalid Input

Location 8

Invalid Input

Date 8

Invalid Input

Location 9

Invalid Input

Date 9

Invalid Input

Next of Kin Details

Next of Kin Name(*)

Invalid Input

Relationship to Veteran(*)

Invalid Input

Next of Kin Address

Invalid Input

Contact Number(*)

Invalid Input

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

Invalid Input

2nd Childs D.O.B

Invalid Input

2nd Childs Relationship to Veteran

Invalid Input

3rd Childs Name

Invalid Input

3rd Childs D.O.B

Invalid Input

3rd Childs Relationship to Veteran

Invalid Input

4th Childs Name

Invalid Input

4th Childs D.O.B

Invalid Input

4th Childs Relationship to Veteran

Invalid Input

5th Childs Name

Invalid Input

5th Childs D.O.B

Invalid Input

5th Childs Relationship to Veteran

Invalid Input

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

Invalid Input

GP Surgery(*)

Invalid Input

GP Address(*)

Invalid Input

GP Contact Number(*)

Invalid Input

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(*)

Invalid Input

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

Invalid Input

Risk Issues – Self/Others:

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

YesNo Invalid Input

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