North Staffordshire Wellbeing Service Self-Referral Form

Please could you complete all the fields below. When you have finished click on “Submit”.
Please provide at least one contact number.
We are only able to accept your referral if you are registered with a North Staffordshire Practice. If you are registered with a Stoke-on-Trent GP Practice, for which the commissioned service is Stoke-on-Trent Healthy Minds, you will need to contact them directly.
Please could you write a brief description of your problem. Please try to describe: