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Merton Uplift Professional Referral Form

Please give as much detail as possible.

(If not please state why not below)

If unsure please leave unticked

Please answer all sections

Section A: To be completed for all referrals

To ensure clinical safety you may be contacted for further information. Please attach the following specific information.

EMIS summary (required for all GP referrals)

If you are unable to upload the EMIS summary please email this to our secure email address ssg-tr.mertonuplift@nhs.net

Please enter your up-to-date contact details


IF YES, please state language and dialect required:

Referrer Details

Medical Details

Section B: Please provide as much information as you have available

Please give as much information as possible including current symptoms.
e.g. suicide, self-harm, risk of self-neglect, risk to others, protective factors.
Please note that we rely on information about risk to judge the urgency of a referral. If it is left blank we will assume there is no risk.
Please give details of type, quantity, frequency


  • Recovery College
  • Imagine Independence
  • Sutton Age UK
  • Off the Record
  • Off the Record