Self Referral Form
Personal Details
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
First Name:*
Last/Family Name:*
Date of Birth:*
Gender:*
Female
Male
Transgender female
Transgender male
Intersex
Gender Fluid
Non-binary
Not known
Not specified
Address Line 1:*
Address Line 2:
Town/City:
County:
Postcode:*
Mobile Number:*
Permission to leave voicemail?*
Yes
No
Permission to send texts?*
Yes
No
Email address:*
Permission to send email?*
Yes
No
Further Details
Do you need an interpreter?*
Yes
No
Preferred Language:*
Please Select A Value...
Akan (Ashanti)
Albanian
Amharic
Arabic
Bengali & Sylheti
Brawa & Somali
British Signing Language
Cantonese and Vietnamese
Dutch
English
Farsi (Persian)
Finnish
Flemish
French
Gaelic
German
Greek
Gujarati
Hausa
Hebrew
Hindi
Igbo (Ibo)
Italian
Japanese
Korean
Kurdish
Lingala
Luganda
Makaton (sign language)
Malayalam
Norwegian
Pashto (Pushtoo)
Polish
Portuguese
Punjabi
Russian
Serbian/Croatian
Sinhala
Somali
Spanish
Swahili
Swedish
Tagalog (Filipino)
Tamil
Thai
Tigrinya
Turkish
Urdu
Vietnamese
Welsh
Yoruba
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
Sexuality:*
Please Select A Value...
Heterosexual
Lesbian or gay
Bisexual
Other
Not known
Not stated
GP Practice:*
Are you NHS or social care staff?*
NHS
Social care
Organisation:*
Role:*
We gather further information on role and organisation to better inform our services and the care we are providing. We will not share any details with your workplace unless it is agreed after assessment that an occupational health referral is needed.
What is the main problem?* (brief description)
How did you hear about Keeping Well?*
Permission to contact your OH department (if necessary)? Please note only relevant information will be shared (e.g. when work is significantly impacting health or health is significantly impacting work). This will be discussed with you before any contact is made*
Yes
No
Do you consent to your anonymised data being used for research purposes?*
Yes
No
Do you consent to being contacted for research purposes?*
Yes
No
The next step is we will call you for a telephone assessment to find out more about your difficulties and discuss next the support options available.
Assessments are available Monday - Friday, between 8am and 4.15pm.
Please specify your availability for a telephone assessment e.g. Tuesday 10-11, Friday 9-3.30pm, or 'Monday' or 'anytime'.
Please offer as may times as you can:*
(If you would prefer to speak to us before arranging this, please call us on 020 3228 3563 or email slm-tr.keepingwell.sel@nhs.net)
Permission to inform GP of referral and outcome of referral:*
Yes
No
Please note we always share information about risk with GPs. Even if you select no here, any risk concerns will be shared with your GP.
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