Birmingham Healthy Minds

Self Assessment Form
Please answer each question as fully as possible.

Personal Information

You must be over 16 to access this service, if under 16 please call Forward thinking Birmingham on 0300 300 0099
(Please only provide if you give permission for us to email you including information about your care)
Please provide us with at least one contact number.

Reasons for referral

If we have any concerns about your or someone else’s safety we will contact your GP and share any relevant information with them.
Please note, Birmingham Healthy Minds is not a crisis service. If you are currently experiencing distressing thoughts and feel you may be at risk of harming yourself or someone else, please contact one of the following: Your GP or out-of-hours service / NHS Direct on 111 / The Samaritans on 116 123.
In an emergency dial 999 or visit A&E.

What happens next?

Thank you very much for completing these questions. We will contact you once we have reviewed this form.