Sheffield Talking Therapies Outreach form
Sheffield Talking Therapies Outreach form
To register for your wellbeing session please fill in the fields below. All information is recorded securely and confidentially on our data record system. If you would like to know more about how your information is stored please see https://www.sheffieldtalkingtherapies.nhs.uk/privacy
Please note - if this booking is less than 72 hours before the start of the course you would like to book onto, please ensure you’re contacting our admin team on 0114 2264380 to ensure you’re sent confirmation and attendance details ahead of the group
Date of session(s):
Type of session:
Please Select A Value...
Wellbeing Wednesday
Workplace wellbeing session
Student session
If this session is within your workplace, please indicate the name of your workplace here:
Title:
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
Mx
First Name:
Last Name:
Date of Birth:
Gender:
Male
Female
Not specified
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
Not known - Patient Declined
Address Line 1:
Address Line 2:
Town/City:
County:
Postcode:
Home Phone Number:
Do you give consent for us to leave a message on this number? This consent will include if another person answers your phone:
Yes
No
Mobile Phone Number:
Do you give consent for us to leave a message on this number? This consent will include if another person answers your phone:
Yes
No
Would you like us to send you SMS Text Reminders for the session?:
Yes
No
Registered GP Surgery:
Email Address:
Are you currently a student?
Yes
No
Please check your email in the week before your session, as we will send you further information including the link to join the session (if attending a virtual session). Please check your junk mail or spam folder.
Please note: It is important you provide an email address so we can send attendance details. However, if you do not have an email address, please input the following: noemail@nhs.net
If you have any additional accessibility requirements please contact us in advance of the session.
Please complete the captcha
Submit
Cancel
