Self Referral Form
Your Details
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
Sister
Lord
Sir
First Name:*
Last Name:*
Date of Birth:*
Gender:*
Male (including trans man)
Female (including trans woman)
Non-binary
Other
Not stated
Address Line 1:*
Address Line 2:
Town/City:*
County:*
Postcode:*
Accommodation Type:*
Please Select A Value...
Owner occupier
Tenant - Local Authority/Housing Association/Registered Landlord
Tenant - private landlord
Nursing Home for older persons
Sheltered housing for older persons
Staying with friends/family as a short term guest
Other
Not known
Homeless
Contact Details
Mobile Number:
Permission to contact by text?:
Yes
No
Permission to leave voicemail on mobile number?:
Yes
No
Other number (e.g. landline):
Permission to leave voicemail on other number?:
Yes
No
Email:
Permission to contact you by email?:
Yes
No
We may need to email some forms (Web-forms) to complete prior to any assessment with us. Can we send you our web-forms?:
Yes
No
GP Name:
GP Practice:*
Other Personal Details
National identity:
Please Select A Value...
British
English
Irish
Scottish
Welsh
Other
If other, please specify:
Ethnicity:
Please Select A Value...
White - British
White - Irish
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Any other Asian background
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Any other Black background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
Religious Group:
Please Select A Value...
No religious group or secular
Atheist / Agnostic
Buddhist
Christian
Church of England
Hindu
Jain
Jewish
Muslim
Other Christian
Other protestant
Orthodox Jewish
Orthodox Christian
Parsi / Zoroastrian
Rastafarian
Roman Catholic
Shi'ite Muslim
Sikh
Sunni Muslim
Any other religion
Other
Are you able to communicate in spoken English?:
Yes
No
Are you able to read and write in English?:
Yes
No
Do you have another preferred Language? if so please state:
Please Select A Value...
Akan (Ashanti)
Albanian
Amharic
Arabic
Bengali & Sylheti
Brawa & Somali
British Signing Language
Cantonese
Cantonese and Vietnamese
Creole
Dutch
English
Ethiopian
Farsi (Persian)
Finnish
Flemish
French
French creole
Gaelic
German
Greek
Gujarati
Hakka
Hausa
Hebrew
Hindi
Igbo (Ibo)
Italian
Japanese
Korean
Kurdish
Lingala
Luganda
Makaton (sign language)
Malayalam
Mandarin
Norwegian
Pashto (Pushtoo)
Patois
Polish
Portuguese
Punjabi
Russian
Serbian/Croatian
Sinhala
Somali
Spanish
Swahili
Swedish
Sylheti
Tagalog (Filipino)
Tamil
Thai
Tigrinya
Turkish
Urdu
Vietnamese
Welsh
Yoruba
Other
Are you able to read and write in your preferred language?:
Yes
No
Do you require an Interpreter?:
Yes
No
Sexuality:*
Please Select A Value...
Heterosexual
Gay (Male)
Gay (Female)
Bisexual
Other
Not stated
Not known
Are you a parent with caring responsibilities for a child or children under 2, or are you or your partner currently pregnant?:
Yes
No
Are you a Military Veteran whose current psychological difficulties are directly related to your military service?:
Yes
No
Do you have a disability?:
Yes I have a disability
No I don’t feel I have a disability
I don’t want to say
If you selected yes, please provide details of your disability: this will enable the service to meet any access needs i.e. use of a lift, ensuring wheelchair access, access to BSL, hearing loop access etc.
Do you have any of the following Long Term conditions?:
Yes
No
Unknown
Not stated
Asthma
Respiratory
Cancer
COPD
Fatigue/Chronic Pain
Dementia
Diabetes
Epilepsy
Cardiac disorders
Digestive tract conditions
Musculoskeletal conditions
Skin conditions including eczema
Diagnosed personality disorder
Bi-polar
Schizophrenia
Do you have a Medically-Unexplained Condition?:
Irritable Bowel Syndrome
Chronic Fatigue Syndrome/ME
Medically Unexplained Symptoms (not specified)
None of these
Are you currently attending?:
Please Select A Value...
School
College
University
Other education
No
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