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Make a Referral to Solace 2
Current
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Page 3
Complete
Please enter the client's details below. An asterisk indicates the field is required
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)
Urban House Women's Wellbeing Group
Leeds Asylum Contingency Hotels Wellbeing Group
Resettlement Programme Parent's Group
Sheffield Stress Management Group (SMG) (currently online)
Bradford Youth Therapy Group
Leeds Youth Therapy Group
Drama Group
Leeds Stress Management Group (SMG)
First Name
Last Name
Gender
Female
Male
Transgender
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 Ameican
Chinese
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
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
Pashtu
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
Uzbek
Vietnamese
Wolof
Xhosa
Youruba (Nigeria)
Zulu
Uyghur
Needs an Interpreter?
Yes
No
Referral Details
Date Referred
Date Referred: Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Date Referred: Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Date Referred: Year
Year
1900
1901
1902
1903
1904
1905
1906
1907
1908
1909
1910
1911
1912
1913
1914
1915
1916
1917
1918
1919
1920
1921
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
2025
2026
2027
2028
2029
2030
2031
2032
2033
2034
2035
2036
2037
2038
2039
2040
2041
2042
2043
2044
2045
2046
2047
2048
2049
2050
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
Referred through Syrian Resettlement Programme?
Yes
No