London Veterans Service referral form

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NHS Veterans Mental Health and Wellbeing Service - London region referral form

We provide Op COURAGE Services for veterans who live in London. You can find out about Op COURAGE Services in other areas by visiting the Government website.

Please note: our Service does not provide 24-hour emergency care. In an emergency you are advised to contact your GP, local NHS crisis number, attend your nearest A&E Department or dial 999.

Please complete the form as much as possible. Some fields are mandatory. We require this information to process your referral. To refer to the service you must click the Finish button at the end of the form.

Personal information

Note: Questions marked by * are mandatory

*This is a mandatory field. Client name

*This is a mandatory field. Date of Birth

Gender

Male
Female
Transgender
Rather not say

*This is a mandatory field. Is the person high risk to self/others, or using NHS crisis / in-patient services?

Please note: our Service does not provide 24-hour emergency care. In an emergency you are advised to contact your GP, local NHS crisis number, attend your nearest A&E Department or dial 999.

*This is a mandatory field. Client address

*This is a mandatory field. Telephone number

Email address

Do you consent to us contacting you by:

Text message
Voicemail message
Email

NHS Number (if known)

Nationality

Religion (if you prefer not to state your religion, please write 'prefer not to say in the answer box).

Relationship status

Employment status

Communication difficulties?

Yes
No

Branch of Armed forces

Army
Royal Navy
RAF
Royal Marine

Regular or Reserve

Regular
Reserve

*This is a mandatory field. Service number

Year enlisted

Year discharged

	Yes	No
Are you Currently Enlisted?
If yes, do you have a discharge date?

Rank on discharge

Were you Deployed Operationally?

Yes
No

If yes, please state each tour with approximate years:

How did you hear about us?

* Spam Guard: Is a stop sign red or blue?

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