Online Self Referral Form
Thank you for answering our questions and accepting our terms and conditions. You will now be asked for some further information so that we can accept your referral and register your details on our systems.
If you experience any issues when submitting your form please contact 01744 415650 and our Business Support team will be able to help, thanks for your patience.
Your Personal Information
Title:*
Please Select A Value...
Mr
Miss
Mrs
Ms
Dr
Prof
Rev
Mx
First Name:*
Last Name:*
Previous Names:
NHS Number:
Everyone registered with the NHS in England and Wales has their own unique number. Your NHS number is normally shown in a '3-3-4' format e.g. 943 476 5919 (this is an example number only) and it can be found on any letter or document you have received from the NHS, such as prescriptions, test results, and appointment letters. Please enter it here as 10 digits with no spaces.
Date of Birth:*
Gender:*
Female (including trans-woman)
Male (including trans man)
Non-binary
Prefer not to say
Prefer to self describe
Please self describe your gender:
Is gender the same as that assigned at birth?:*
Please Select A Value...
Yes - the person's gender identity is the same as their gender assigned at birth
No - the person's gender identity is not the same as their gender assigned at birth
Prefer not to say
Pronouns:*
Please Select A Value...
Ae/Aer/Aer
Ey/Em/Eir
Fae/Faer/Faer
He/Him/His
Per/Per/Pers
She/Her/Her
They/Them/Their
Ve/Ver/Vers
Xe/Xem/Xyr
Ze/Hir/Hir
Address
Address Line 1:*
Address Line 2:
Town/City:*
County:
Postcode:*
Contact Information
Home Number:
Mobile Phone:
Is it ok to leave messages on your home phone?
Yes
No
Is it ok to leave messages on your mobile phone?
Yes
No
Would you like us to send text reminders of appointments?
Yes
No
Are you happy to receive the following, video consultation or telephone or either?
Video consultation
Telephone
Either
Email Address:
Can we contact you via email in order to send you treatment questionnaires?
Yes
No
Are you willing to provide details of your Next of Kin?*
Yes
No
Next of Kin Name:
Next of Kin Contact Number:
About You
National Identity:*
Please Select A Value...
British
English
Irish
Scottish
Welsh
Other
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 backgrond
Mixed - White and Asian
Mixed - White and Black African
Mixed - White and Black Caribbean
Mixed - Any other mixed background
White - British
White - Irish
White - Any other White background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not known - Not known
Not Stated - Not Stated
Religion/ Belief Affilliations:*
Please Select A Value...
Baha'i
Buddhist
Christian
Hindu
Jain
Jewish
Muslim
Pagan
Parsi / Zoroastrian
Sikh
Other
No religious group or secular
Declines to disclose
Patient Religion Unknown
Main Spoken Language:
Please Select A Value...
Akan
Albanian
Amharic (Ethiopian)
Arabic
Bengali including Sylheti
British Signing Language
Chinese Cantonese
Chinese Hakka
Chinese Mandarin
Dutch; Flemish
English
Farsi (Persian)
Finnish
French
Gaelic; Scottish Gaelic
Ganda/Luganda
German
Greek
Gujarati
Haitian; Haitian Creole
Hausa
Hebrew
Hindi
Igbo (Ibo)
Italian
Japanese
Korean
Kurdish
Lingala
Makaton (sign language)
Malayalam
Norwegian
Polish
Portuguese
Punjabi
Pushto; Pashto
Russian
Serbian
Sinhalese/Sinhala
Slovak
Somali
Spanish
Swahili
Swedish
Tagalog (Filipino)
Tamil
Thai
Tigrinya
Turkish
Urdu
Vietnamese
Welsh
Yoruba
Do you require an Interpreter?
Yes
No
Sexual Orientation:*
Please Select A Value...
Heterosexual/Straight
Bi
Gay Man
Lesbian/Gay Woman
Prefer not to say
Prefer to Self Describe
Please self describe your sexuality:
Relationship Status:
Please Select A Value...
Co-Habiting
Divorced/Person whose Civil Partnership has been dissolved
Married/Civil Partner
Separated
Single
Widowed/Surviving Civil Partner
Not Disclosed
Accommodation Type:
Please Select A Value...
Accommodation tied to job (including Armed Forces)
Admitted patient settings
Bed and breakfast accommodation to prevent or relieve homelessness
Care home with nursing
Care home without nursing
Criminal justice settings
Hostel to prevent or relieve homelessness
Living with family
Living with friends
Mobile accommodation
Owner occupier
Rough sleeper
Sleeping in a night shelter
Sofa surfing (sleeps on different friends floor each night)
Specialist Housing (with suitable adaptations to meet impairment needs and support to live independently)
Squatting
Staying with friends/family as a short term guest
Temporary housing to prevent or relieve homelessness
Tenant - Local Authority/Arms Length Management Organisation/Registered Landlord
Tenant - private landlord
University or College accommodation
Other (not listed)
Medical
Do you have any long term health conditions (if yes, please select from the list)?
Please Select A Value...
Cancer
Cardiac - Abnormal Heart Rhythms
Cardiac - Aorta Disease
Cardiac - Congenital Heart Disease
Cardiac - Coronary Heart Disease
Cardiac - Heart Failure
Cardiac - Heart Muscle Disease
Cardiac - Hypertension
Cardiac - Hypotension
Cardiac - Other Cardiac Disease
Cardiac - Pericardial disease
Cardiac - Vascular Disease
Chronic Fatigue
Chronic Kidney Disease
Chronic Liver Disease
Chronic Musclo-skeletal
Chronic Obstructive Pulmonary Disease
Chronic Pain - Atypical Facial Pain
Chronic pain - Chronic pain syndrome
Chronic Pain - Fibromyalgia
Chronic Pain - Loin Pain haematuria syndrome
Chronic Pain - Nerve Damage
Chronic Pain - Other Chronic Pain
Chronic Pain - Pain in Pelvis
Chronic Pain - Persistent Pain from Injury
Chronic Pain - Persistent Pain from Surgery
Chronic Pain - Rheumatoid Arthritis
Chronic Pain - Skeletal Changes/Damage
Chronic Pancreatitis
Diabetes - Type 1
Diabetes - Type 2
Digestive - Crohn's disease
Digestive - Diverticulitis
Digestive - Ulcerative Colitis
Epilepsy
Gynaecological - Dysmenorrhea
Gynaecological - Polycystic ovary sydrome
Gynaecological- Endometritis
Medically Unexplained Conditions
MSK - Spondylitis
MUS - Chronic Fatigue Syndrome/ Myalgic Encephalomyelitis (ME)
MUS - Digestive Tract Condition
MUS - Irritable Bowel Syndrome
MUS - Non-Epileptic attack disorder
MUS - Other Medically Unexplained Symptoms
Neurological Conditions - Acquired Brain Injury
Neurological conditions - Attention deficit hyperactivity disorder
Neurological conditions - Autistic disorder
Neurological Conditions - Dementia
Neurological Conditions - Epilepsy
Neurological Conditions - Multiple Sclerosis
Neurological Conditions - Other Neurological Conditions
Neurological Conditions - Parkinson's Disease
Neurological Conditions - Stroke
Osteoarthritis
Osteoporosis
Paralysis
Respiratory - Asthma
Respiratory - COPD
Respiratory - Other Respiratory Disease
Respiratory - Pulmonary disease
Skin Conditions - Eczema
Skin Conditions - Other Skin Conditions
Do you have a disability?:*
Yes
No
Disability:
Please Select A Value...
Behavioural and emotional including Autism Spectrum condition
Hearing
Learning disability/Learning difficulty
Manual Dexterity
Mobility and Gross Motor
Other
Perception of Physical Danger
Personal, Self Care and Continence
Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits etc)
Sight
Speech
Are you ex-British armed forces?*
Please Select A Value...
Yes - ex services
Not an ex-services member or their dependant
Dependant of a ex-serving member
Not stated (Person asked but declined to provide a response)
Unknown (Person asked and does not know or isn't sure)
Do you require wheelchair access?
Please Select A Value...
Yes
No
Are you expecting a child or have a child under 24 months?
Yes
No
Your GP Details
We can only accept referrals from patients registered with GP practices within the St Helens area, if you are unsure if your GP Practice falls under our catchment area please visit our website for a list of the GP Practices we cover, if your GP practice does not fall in this area please refer to "Getting the right support" page on our website for details of alternative services in your area.
Practice Name:*
GP Name:
Appointment Details
Would you be happy to have appointments remotely via video consultation?:*
Yes
No
Do you have a preference for the gender of your therapist?:*
No preference
Male
Female
How did you hear about us?
Please Select A Value...
GP
Leaflet
Family/Friend
Other healthcare professional
Search engine (e.g. Google)
Social media (e.g. Twitter, Facebook)
Other
View our Privacy & Confidentiality Policy at: https://www.talkliverpool.nhs.uk/privacy-and-confidentiality
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