This form is for agencies and organisations referring on behalf of their client only. For self-referrals please contact Mentis head office by either emailing [email protected] or by calling our us on 07821484400.

All sections of this form must be completed.
Failure to do so may cause delays.
If for any reason a section cannot be filled out, please state why.
Blank sections will not be accepted. Additional documents can be attached and uploaded at the end of the application form.
If for any reason you cannot fully complete this form, you can save your progress securely and resume it later. You will have 30 days to complete the form before the data is erased from our secure servers.

Please be aware that your data may be shared with local authority Housing Benefit departments; the referral agency that directed you to Mentis (e.g. Social Services or Health), Home Providers under the Mentis Midlands C.I.C umbrella and also with other bodies (such as Police or the Courts or Probation – if appropriate) where they have a legal right to access. In all such cases, Mentis Midlands C.I.C will ensure that a ‘data exchange agreement’ is in place, which will ensure that data is only used for legitimate purposes. This is however subject to one important exception. In some limited circumstances, we may be legally required to share certain personal data, if we are involved in legal proceedings or complying with legal obligations, a court order, or the instructions of government authority. In these instances, we will always endeavour to inform the individual concerned. 

Referral Application
Step 1 of 9
Agency Name
This must be accurate. All referrals must meet the definition of 'Vulnerable Adult' - "A Vulnerable Adult is someone aged 18 or over; who is, or may be, in need of community services due to age, illness or a mental or physical disability. Who is, or may be unable to take care of himself/herself, or unable to protect himself/herself against significant harm or exploitation."