StRaW Referral Form – Encapsulate

Sustaining Resilience at Work (StRaW) is a programme designed by mental health experts to assist anyone experiencing stress, regardless of the trigger, if it is having an impact on them at work. We have fully-trained StRaW practitioners who can listen to you, in confidence, and help you come up with a plan to help you feel better. This form allows you to refer yourself, or a member of your team if you are a manager, for a StRaW assessment with one of our practitioners.

Unique ID

Your Name(Required)

First Last

Your Contact Number(Required)

Your Email Address(Required)

Your Job Title(Required)

Your Department / Ward(Required)

Your place of work(Required)

Hull Royal Infirmary

Castle Hill Hospital

Other – please specify

Please specify(Required)

Are you referring an individual?(Required)

Yes – I am referring an individual

No – this referral is for myself

Name of the person you are referring(Required)

First Last

Have they consented to this referral?(Required)

Yes

Brief outline of issue(Required)

Phone

This field is for validation purposes and should be left unchanged.

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Any person identifiable data you submit via this form is stored on a secure database server in England, which only the relevant authorised healthcare professionals can access.
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Our processes for collecting data via this website have been approved by the Hull University Teaching Hospitals NHS Trust Information Governance Committee.
We are fully compliant with GDPR and the Data Protection Act 2018.
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