N.O.W's the time for change

Self referral registration

Please use this form if you are an individual / family self-referral, looking to use our services.

Important

This form is only for self referrers who have received a letter from EWHMS Single Point of Access. Please continue to complete this self referral form and upload your letter at the bottom.

If you are wanting to make a new referral into NOWs please contact EWMHS Single Point of Access on 0800 9530222. If you are an organisation or GP please contact us for more information.

Parent / guardian First Name(s)

Parent / guardian Surname

Best contact telephone number

Parent / Carers contact number

Home address line 1

Home address line 2

Home address - town

Home address - county

Home address - postcode

Email address

Parent / Carer

Registering as

Date of birth of child / young person

If you are referring in more than one member of your family, please confirm DOB next to each name in the next box.

First name(s) of child / young person for referral

Surname of child / young person for referral

If different to parent / guardian

NHS Number of everyone being referred in

Gender of referral

Female

Male

Other

Prefer not to say

Where did you receive the referral details for N.O.W's Resilience Programmes?

E.g. NELFT / EWHMS Single Point Of Access

Quadrant Area

Preferred contact method

By phone

By email

How many members of the family are there that live in the same house?

Please include age ranges of adults & children

How many family members will be taking the virtual 1-2-1 sessions?

Please include parents / guardian, children aged 4+

Programme Selection

Clinical Aromatherapy Consultation & Tailored Blend

6 Steps to Emotional Resilience And Wellbeing Kids (aged 4-7)

6 steps to Emotional Resilience And Wellbeing Young People (aged 8-17)

6 Steps to Emotional Resilience And Wellbeing Adults

Please tick to agree to the following terms

I agree to be accountable for each session, to be educated on the wellbeing techniques that will be coached / mentored via N.O.W's Team.

I understand that I will be responsible for making the sessions (or for ensuring a minor taking the child course) on time and if for any circumstances the session cannot be adhered to the time / date booked, I have 48hrs before the date to notify N.O.W's head office by email or phone in order to reschedule the session.

If any session is missed and N.O.W's is NOT notified, the week will be deducted from the overall 6/12 week programme.

School Name

Name of the School for Referral

School Contacts Number

School SENCO/ Pastoral / Mental Health lead Email AddressEmail Address

GP Details

Please include GP Name, Surgery Address And Phone Number

Are you or the family member for referral(s) on any medication? If so please list