Mental Health Integrated Networking Team Hub
GP Referral Form

bnssg.wwv.imhthub@nhs.net
bnssg.wwv.minthub@nhs.net

Patient details
Full name :  
Preferred name: 
Gender Female 
NHS Number : 
Date of birth: 
Marital status:  
Address: 
Postcode: 
Home telephone number  
Mobile telephone number: 
Religion/Belief:  
Main language: 
Ethnicity: 
Interpreter required?:   

Referrer details
Date of referral: 
Referring GP: 
Registered GP name and address: 
Referring GP telephone number:  

Consent:
Has the person consented to a referral to this service (mandatory field)?:

Additional supportive information:

Patient Consultations