Self Referral Form
First name(s):*
Last name(s):*
Preferred Name:
Gender:*
Male
Female
Other
Not Stated
Preferred Pronoun:
Please Select A Value...
She/Her/Her
He/Him/His
They/Them/Their
Ae/Aer/Aer
Ey/Em/Eir
Fae/Faer/Faer
Per/Per/Pers
Ve/Ver/Vers
Xe/Xem/Xyr
Ze/Hir/Hir
Date of Birth (dd/mm/yyyy):*
NHS Number (if known):
Ethnicity:*
Please Select A Value...
Asian or Asian British - Bangladeshi
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Any other Asian background
Black or Black British - African
Black or Black British - Caribbean
Black or Black British - Any other Black background
Mixed - White and Asian
Mixed - White and Black African
Mixed - White and Black Caribbean
Mixed - Any other mixed background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
White - British
White - Irish
White - Any other White background
Not known - Not known
Not Stated - Not Stated
Address Line 1:*
Town/City:*
Postcode:*
Email:*
Alternative Email address:
Home Number:
Do you give permission for us to leave a message on this number? This will include if another person answers your phone:
Yes
No
Mobile Number:*
Do you give permission for us to leave a message on this number? This consent will include if another person answers your phone:*
Yes
No
Permission to send SMS:*
Yes
No
Alternative contact number:*
Do you give permission for us to leave a message on this number? This consent will include if another person answers your phone:*
Yes
No
Do you have any difficulties in communicating? (E.g. deafness, anxiety on the phone, etc. If yes please state your difficulty and why you may find it difficult):
Parent / Carer Information
First name:*
Last name:*
Relationship with you:*
Do you have a carer:
Yes
No
Is parent address the same as above:
Yes
No
Address (if different to above):
Phone:*
Email:
Does this person have parental responsibility for you?:*
Yes
No
Is this the person you live with?:
Yes
No
Other Information
GP Surgery:*
Contact details (if known):
Name of school / College:*
If you are not registered at a school, please put 'Not in school'.
Referral Reason
Please describe any mental health difficulties you might be having, e.g. worries, sadness, anger, changeable moods or feelings, self-harm etc:*
How long have these been affecting you?:
Is there any further information that you think we should know? For example, Do you still go to school? What activities do you enjoy doing?:
Are you currently working with, or have you worked with, any other agencies, people or organisations, including your school?:
Referrer Information
Name:*
Address:*
Phone:
Email:*
Relationship to child / young person:
Is the young person aware this referral is being made on their behalf?:
Yes
No
Are you a professional referring?
Yes
No
If yes, are there any additional comments to add:
Please complete the captcha
Submit
Cancel
