Self Referral Form
Self Referral Form
Brief questions to help understand the support that would suit you.
Please let us know if you want support to complete the form.
Confidentiality: Just so you know – if in working with us we become aware that you or a 3rd party is at risk then we will need to inform relevant agencies to ensure that the right support is provided.
Personal Details
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Mx
Dr
Rev
Prof
First Name:*
Last Name:*
Date of Birth:*
Gender:*
Male
Female
Other
Address Line 1:*
Address Line 2:
Town/City:*
County:*
Postcode:*
Permission to send letters to your home address:*
Yes
No
Email:*
Can we email you?:*
Yes
No
Preferred contact number:*
Can we leave a voicemail?:
Yes
No
Can we text you?:
Yes
No
SMS messages allow us to send you appointment reminders and service information via text message.
Are you pregnant/have or have you given birth in the last 12 months?:*
Yes
No
Have you ever served in the armed Forces?:*
Yes
No
If yes for the above is this:
Ex Military
Current Military
Are you a NHS worker, Care home Worker?:*
Yes
No
GP Details
GP Surgery:*
Permission to inform GP of referral and outcome of referral:
Yes
No
Additional Info
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 - Tamil
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 - Eastern European
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
Religion:
Please Select A Value...
No religious group or secular
Atheist / Agnostic
Church of England
Other protestant
Orthodox Christian
Roman Catholic
Other Christian
Muslim
Shi'ite Muslim
Sunni Muslim
Sikh
Jewish
Orthodox Jewish
Buddhist
Hindu
Jain
Parsi / Zoroastrian
Rastafarian
Any other religion
Not stated
Sexual Orientation:
Please Select A Value...
Heterosexual
Lesbian or gay
Bisexual
Other
Not known
Not stated
Marital Status:
Please Select A Value...
Single
Married
Divorced
Widowed
Separated
Co-Habiting
Long term
Civil Partnership
Not Disclosed
Other
Do you have a Long-Term Physical health condition?
Please Select A Value...
Yes
No
Diabetes
Heart disease
Chronic Obstructive Pulmonary Disease (COPD)
Other
If other, please state:
We can support you with difficulties in coming to terms with a long-term physical health condition and in any learning to follow health advice. Are you referring to Merton Uplift for this type of support?:
Yes
No
Do you require an interpreter?:*
Yes
No
If you require an interpreter, please specify your preferred language:
To help us to support you to access the service, can you let us know if any of the following apply to you:
Learning Disability
Hearing Impairment
Visual Impairment
Mobility Issues
Difficulties with reading and/or writing
Other (please state below)
If other, please state:
Are you being seen by the Community Learning Disability Team?:
Yes
No
If yes, can we contact the Community Learning Disability Team to discuss your referral to us?:
Yes
No
Can you describe the main reason you have referred yourself to the service?:
Are you interested in any of the following wellbeing workshops?:
Self-Care & Relaxation
Overcoming Anger & Irritability
Coping with Stress
Reaching your potential
Maintaining your wellbeing as a new parent
Assertiveness and Confidence
Thank you so much for providing that detail – the referral will be discussed with a team leader to ensure the appropriate team contacts you in due course.
How did you hear about Merton Uplift?:
Please Select A Value...
GP
CAB
Advert
Website/Internet
Word of Mouth
Local Charity
Community event
Faith Organisation
Employer/College
Used before
Other Health Services
Job Centre
Leaflet drop
Google search
Social media
In order to reduce waiting times and ensure timely assessment and treatment, we work closely in partnership with digital providers. These providers are currently Xyla digital therapies, IESO and Silver Cloud.
Do you consent to sharing your information and being contacted by these services if appropriate?*
Yes
No
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