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Make a Referral to Solace 2
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Please enter the client's details below. An asterisk indicates the field is required
Does the person know you are making the referral and consented for Solace to hold their data on our database?
No
Yes
Please note that it is not possible to submit this referral without their consent.
This is a Referral for Group Support Only?
Yes
No
Select which group you would like to refer to:
- Select -
Leeds/Bradford Farsi Speaking Men’s Group (hybrid Manor House/Online)
Leeds Women’s Wellbeing Group (currently online)
Resettlement Programme Parent's Group
Bradford Young People Psychoeducation Group (Refugee Action Referrals only)
Sheffield Stress Management Group - Referrals from Sheffield City of Sanctuary Only
Bradford Youth Therapy Group (Bevan Referrals only)
First Name
Last Name
Gender
Female
Male
Other
Birth Date
NHS Number
Phone Number
Email
Street Address
Street Address Line 2
City
Postcode
County
- None -
Country
United Kingdom
Immigration
Country of Origin
- Select -
Afghanistan
Albania
Algeria
Andorra
Angola
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas, The
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia
Botswana
Brazil
Britain
Brunei
Bulgaria
Burkina Faso
Burma
Burundi
Cabo Verde
Cambodia
Cameroon
Canada
Cape Verde
Cape Verdi Isla
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Cyprus
Czechia (Czech Republic)
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equador
Equatorial Guinea
Eritrea
Estonia
Eswatini (former Swaziland)
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Hngry
Holland
Holy See
Honduras
Iceland
India
Indonesia
Iran
Iraq
Ireland
Isreal
Italy
Ivory Coast
Jamaica
Japan
Jordan
Kazakhstan
Kenya
kiribati
Kosovo
Kurdistan
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lebenan
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar (formerly Burma)
Namibia
Nauru
Ndelebe
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
North Korea
North Macedonia
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Qatar
Rohingyia
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Korea
South Sudan
Spain
Sri Lanka
St Lucian
Sudan
Suriname
Sweden
Switzerland
Syria
Taiwan
Tanzania
Thailand
Timor-Leste
Togo
Tonga
Trinida
Tunisia
Turkey
Turkmenistan
Uganda
UK
Ukraine
United Arab Emirates
Uruguay
USA
Uzbekistan
Vantuatu
Venezuela
Verde
Vietnam
Yemen
Zambia
Zimbabwe
Date of arrival in UK
Home Office/CO/VPR Number
Home Office Status
- Select -
Asylum Seeker
ELR
ILR
Humanitarian Protection
Discretionary Leave to remain
Refugee
Refused Asylum Seeker
Detained
Removed
Marriage Visa
Unaccompanied Minor (UASC)
Privacy Preferences
Do not email
Do not phone
Do not mail
Do not sms
Solace Demographics
Ethnic Identity
- None -
Afghan
Any Other
Arabic
Asian or Asian British - Bangladeshi
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian Other
Black or Black British - African
Black or Black British - Caribbean
Central American
Chinese
Kurdish
Mixed - Any Other Mixed Background
Mixed - White and Asian
Mixed - White and Black African
Mixed - White and Black Caribbean
Not Known/Not provided
other Asian (Middle east)
South American
Tajin
Turkmen
Uzbec
Vietnamese
White - Any Other White Background
White - British
White - Irish
Religion
- None -
Christian
Jewish
Muslim
Buddhist
Hindu
Sikh
Atheist
Other
Not Specified
Relationship Status
- None -
Married
Single
Co-habiting
Civil Partnership
Other
Did not want to answer
Not asked
Child
Identifies as Disabled
Yes
No
Languages Spoken
?
Albanian
Amharic
Arabic
Assyrian
Azeri
Bandjoun
Bashewi
Beluchi
Bemba
Bena
Bengali
Bilen
Bosnian
British Sign Language
Burmese
Cantonese
Chaldean
Chichewa
Creole
Dari
Dutch
Edo
English
Esperanto
Farsi
Finnish
Flemish
French
Fulah
Georgian
German
Greek
Hausa
Hebrew
Herero (Otjiherero)
Hindi
Hindko
Igbo
Ijaw (Kalaburi)
Indonesian
Iroba
Italian
Japanese
Kannada
Kikonga
Kinya Rwanda
Kirundi
Kituba
Korean
Kosovan
Krio (Sierra Leone)
Kurdish Bhadini
Kurdish Sorani
Kurmanji
Latvian
Lingala
Lithuanian
Luganda Run-joakole
Lukiga Rutooro
Lun-jarwanda
Lunoro/Lun-joro
Malay
Maltes
Mandarin
Mandingo
Mandinka
Mirpuri
Ndebele
Nepali
Norwegian
Nyanji
Oromo
Pahari
Pashto
Polish
Portuguese
Punjabi
Rohingyian
Roma
Romanian
Runyankolet
Russian
Serbo-Croat
Shona
Slavic/Slavonic
Somali
Spanish
Sri Lankan
Susu
Swahili
Swati
Swedish
Tajin
Tamil
Thai
Tigre
Tigrinya
Tshiluba
Turkish
Turkmen
Twi
Ugandan
Ukrainian
Urdu
Urdu/Hindi
Uyghur
Uzbek
Vietnamese
Wolof
Xhosa
Youruba (Nigeria)
Zulu
Czech
Needs an Interpreter?
Yes
No
Referral Details
Referral Status
- Select -
Online Referral Awaiting Check
Closed - Referred onwards
Completed (Do not use this status after 1.9.2019)
Completed - Lost communication with client
Completed - Never communication from client
Completed as planned - treatment ended
Deported
Detained
Died
In Existing MH Service
Internal Waiting List
Internal Waiting List Bradford
In Triage
Moved away
Newly Assigned
Not interested
Ongoing
Re - referred to Solace (has been previously referred)
Referred back out to CO
Rejected (Not from eligible referrer)
Rejected - No service in geographical area
Rejected referral (not RAS)
Sheffield SMG Waiting List
SMG Sheffield Ongoing
Solace decline - No capacity
Solace declined - not most appropriate service
Treatment Paused (on hold)
Waiting for ID
Waiting List
Organisation Type
Organisation Type
- Select -
Health - GP
Health - Mental Health Trusts
Health - CMHT
Health - Hospitals
Health - IAPT
Health - CAMHS
Housing
Legal
Voluntary
Statutory
Education
Personal
Other
interpreter agency
therapy rooms for hire