Mental Health Referral

Doctor / GP Surgery

Referrer Information

Title(Required)

First Name(Required)

Surname(Required)

Name of GP / Surgery / Clinic / Hospital(Required)

Role/ Designation

Address Line 1(Required)

Address Line 2(Required)

Address Line 3(Required)

City(Required)

Country(Required)

Postcode(UK)

Phone

Fax

Email(Required)

Website

Patient Information

Title(Required)

First Name(Required)

Surname(Required)

Date of Birth

Medical Record Number (MRN)

Phone

Email Id(Required)

Address Line 1

Address Line 2

Address Line 3

City

Country

Postcode(UK)

Referral Information

Type of Referral / Treatment Requested

Assessments

Recommendations & Treatments

Urgent?

Yes

Risk to Self / Others?

Yes

Reason for Referral (up to 300 words)

Expectation from Referral (up to 300 words)

Upload documents like Occupational health reports, Medical records, Practitioner Reports, Other Relevant Information

I confirm that I agree to Oaktree Connect terms and conditions. This referral is made in good faith, no fees is payable/ paid to Oaktree Connect for the services requested via this website/app nor is there any monetary incentive for the referral.(Required)

I understand that a pre-authorisation and consent of the patient is required for referrals made to Oaktree Connect. I have ensured that if the patient is a minor/ lacks mental capacity to consent, the holder of power of attorney/ parent/ legal guardian has provided this consent.(Required)

Disclaimer: This disclaimer is subject to change and maybe modified from time to time.

HR / Employer

Referrer Information

Title(Required)

First Name(Required)

Surname(Required)

Full Legal Name of Company(Required)

Role/ Designation

Address Line 1(Required)

Address Line 2(Required)

Address Line 3(Required)

City(Required)

Country(Required)

Postcode(UK)

Phone

Fax

Email(Required)

Website

Client Information

Title(Required)

First Name(Required)

Surname(Required)

Phone Number

Email(Required)

Date of Birth

Medical Record Number (MRN)

Address Line 1

Address Line 2

Address Line 3

City

Country

Postcode(UK)

Referral Information

How will the assessment be funded

Type of Referral / Treatment Requested

Occupational Health Report

Ongoing Treatment & Care

Other

Urgent?

Yes

Risk to Self / Others?

Yes

Comments / Nots / Instructions (Max. 150 words)

Upload documents like Occupational health reports, Medical records, Practitioner Reports, Other Relevant Information

I confirm that I agree to Oaktree Connect terms and conditions. This referral is made in good faith, no fee is payable/ paid to Oaktree Connect for the services requested via this website/app nor is there any monetary incentive for the referral.

A pre-authorisation and consent of the patient has been sought from the person referred.(Required)

A pre-authorisation and consent of the patient has been sought from the person referred.

Solicitor / Law Firm

Referrer Information

Title(Required)

First Name(Required)

Surname(Required)

Full Legal Name of Law Firm(Required)

Role/ Designation

Address Line 1(Required)

Address Line 2(Required)

Address Line 3(Required)

City(Required)

Country(Required)

Postcode(UK)

Phone

Fax

Email(Required)

Website

Patient Information

Title(Required)

First Name(Required)

Surname(Required)

Date of Birth

Your Reference Number(Required)

Phone Number

Email(Required)

Address Line 1

Address Line 2

Address Line 3

City

Country

Postcode(UK)

Referral Information

How will the assessment be funded

What kind of a case is it

Type of Referral / Treatment Requested

Assessment & Report

Recommendations & Treatments

Other

Urgent?

Yes

Risk to Self / Others?

Yes

Please specify risk (up to 150 words)

Upload documents like Occupational health reports, Medical records, Practitioner Reports, Other Relevant Information

Social Worker / Local Authority

Referrer Information

Title(Required)

First Name(Required)

Surname(Required)

Full Legal Name of Law Firm(Required)

Role/ Designation

Address Line 1(Required)

Address Line 2(Required)

Address Line 3(Required)

City(Required)

Country(Required)

Postcode(UK)

Phone

Fax

Email(Required)

Website

Patient Information

Title(Required)

First Name(Required)

Surname(Required)

Date of Birth

Your Refarence Number(Required)

Phone Number

Email(Required)

Address Line 1

Address Line 2

Address Line 3

City

Country

Postcode(UK)

Referral Information

How will the assessment be funded

Is your client in Social care

Yes

Urgent?

Yes

Risk to Self / Others?

Yes

Reason for Referral (up to 300 words)

Expectation from Referral (up to 300 words)

Upload documents like Occupational health reports, Medical records, Practitioner Reports, Other Relevant Information

School / University

Referrer Information

Title(Required)

First Name(Required)

Surname(Required)

Full Legal Name of School / Collage / Univercity(Required)

Role/ Designation

Address Line 1(Required)

Address Line 2(Required)

Address Line 3(Required)

City(Required)

Country(Required)

Postcode(UK)

Phone

Fax

Email(Required)

Website

Patient Information

Title(Required)

First Name(Required)

Surname(Required)

Date of Birth

Your Reference Number(Required)

Phone

Email(Required)

Address Line 1

Address Line 2

Address Line 3

City

Country

Postcode(UK)

Referral Information

How will assessment be funded

Type of Referral / Treatment Requested

Occupational Health Report

Ongoing Treatment & Care

Other

Urgent?

Yes

Risk to Self / Others?

Yes

Reason for Referral (up to 300 words)

Comments / Notes / Instructions (up to 300 words)

Upload documents like Occupational health reports, Medical records, Practitioner Reports, Other Relevant Information

Disclaimer: This disclaimer is subject to change and maybe modified from time to time.

Other Organisations

Referrer Information

Title(Required)

First Name(Required)

Surname(Required)

Full Legal Name of Organization(Required)

Role/ Designation

Address Line 1(Required)

Address Line 2(Required)

Address Line 3(Required)

City(Required)

Country(Required)

Postcode(UK)

Phone

Fax

Email(Required)

Website

Patient Information

Title(Required)

First Name(Required)

Surname(Required)

Date of Birth

Medical Record Number (MRN)

Phone

Email(Required)

Address Line 1

Address Line 2

Address Line 3

City

Country

Postcode(UK)

Referral Information

How will the assessment be funded

Urgent?

Yes

Risk to Self / Others?

Yes

Reason for Referral (up to 300 words)

Comment / Notes / Instructions (up to 300 words)

Upload documents like Occupational health reports, Medical records, Practitioner Reports, Other Relevant Information

Disclaimer: This disclaimer is subject to change and maybe modified from time to time.

Welcome to the Oaktree Connect referral page.
We would like to assure you that all the information you provide is strictly
confidential and handled by Oaktree Connect administrative staff manually
in order to action the referral.

Doctor / GP Surgery

Referrer Information

Patient Information

Referral Information

HR / Employer

Referrer Information

Client Information

Referral Information

Solicitor / Law Firm

Referrer Information

Patient Information

Referral Information

Social Worker / Local Authority

Referrer Information

Patient Information

Referral Information

School / University

Referrer Information

Patient Information

Referral Information

Other Organisations

Referrer Information

Patient Information

Referral Information

About

Seek Care

Provide Care

Help

Mental Health Referral

Welcome to the Oaktree Connect referral page. We would like to assure you that all the information you provide is strictly confidential and handled by Oaktree Connect administrative staff manually in order to action the referral.

Doctor / GP Surgery

Referrer Information

Patient Information

Referral Information

HR / Employer

Referrer Information

Client Information

Referral Information

Solicitor / Law Firm

Referrer Information

Patient Information

Referral Information

Social Worker / Local Authority

Referrer Information

Patient Information

Referral Information

School / University

Referrer Information

Patient Information

Referral Information

Other Organisations

Referrer Information

Patient Information

Referral Information

About

Seek Care

Provide Care

Help

Welcome to the Oaktree Connect referral page.
We would like to assure you that all the information you provide is strictly
confidential and handled by Oaktree Connect administrative staff manually
in order to action the referral.