Referral Form — Recovery Hub
This form is to be filled up by the referrer to the Recovery Hub Service.

This service is accessible to people between ages 18-45. They should have an existing diagnosis of mental health illness and should be stable enough to learn skills and work. It is acceptable if the person is on medication, but they should not be having acute psychotic symptoms or suicidal thoughts.

Exclusion criteria — We do not accept referrals for people under the age of 18 and over 45.

People with the following conditions will not be able to use the service:
learning disabilities, autism, dementia, acute psychosis, active suicidal ideation, drug addiction, alcohol addiction.
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Who is this referral for?
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Date of referral *
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DD
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Referrer's Details (Name, Phone, Email)
Referrer's relationship to the service user:
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Details of service user (Name, Phone, Email)
Mental health Diagnosis
Are they stable in their mental state?
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Does the client have any other health problems that could affect your capability to work? If so, list them. *
Is the client on any medication that could cause significant side effects? If so, please list them. *
Do you think they are fit to learn new skills and work?
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What is the service user looking for?
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Are there any specific aids/support measures that the client would require to help with doing work?
If form is not being filled online, please send the completed referral form to:  contact@recoveryhub.in
Thank you for your referral — we will get back to you shortly.
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