Make a Referral

Submit a referral for an independent mental health assessment. We aim to respond within one working day.

Referral Info

Your details and patient information

Consent & Basis

Confirm consent or lawful basis

Submit

Review and send your referral

Response

We respond within 1 working day

Referral Form

1) Your Details (Referrer)

Full Name *

Organisation *

Role *

Email *

Phone Number *

2) Patient Details

Patient Full Name *

Date of Birth *

NHS Number (if known) Optional

3) Assessment Details

Assessment Type *

Urgency

Reason for Referral *

Include the specific decision to be assessed and any relevant history.

Additional Information

4) Consent & Confirmation

I confirm that consent has been obtained from the individual (or there is a lawful basis for this referral under the Mental Capacity Act 2005 or other applicable legislation). * I agree that the information provided will be processed in accordance with data protection legislation and Mwanga's privacy policy. *