Self Referral Form
In taking your details, we recognise the importance of personal privacy and make sure all information about you is held securely in accordance with the General Data Protection Regulation (GDPR)
We use data anonymously for monitoring purposes. However, no one will be able to link any information back to you.
Everything you tell us is kept confidential, however if you disclose information concerning current or potential harm or risk to yourself or another, we may need to tell another party including your GP, the Police or Ambulance Service.
If you disclose current or historical abuse or information related to a crime, we are legally obliged to inform the Police and/or other safeguarding agencies.
To ensure quality of care we are required to share information with your GP about your referral and treatment which we may do both verbally and in writing.
Please confirm that you agree with these terms and conditions:*
Yes
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Mx
Dr
Rev
Prof
First Name:*
Last Name:*
Preferred Name:
Date of Birth:*
Gender:*
Male
Female
Transgender
Gender Non-Binary
Not known
Not specified
Address Line 1:*
Postcode:*
Are you happy for us to send letters to your home address?:*
Yes
No
Mobile Number:*
Can we leave messages:*
Yes
No
Can we contact you by SMS:*
Yes
No
Home Number:
Email Address:*
Can we contact you by email:*
Yes
No
GP practice:*
Your NHS number (if known):
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 - Gypsy/Traveller
Other Ethnic Groups - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
Sexual Orientation:
Please Select A Value...
Heterosexual
Lesbian or gay
Bisexual
Other
Not known
Not stated
Religion:
Please Select A Value...
No religious group or secular
Atheist / Agnostic
Church of England
Other protestant
Orthodox Christian
Roman Catholic
Other Christian
Muslim
Shi'ite Muslim
Sunni Muslim
Sikh
Jewish
Orthodox Jewish
Buddhist
Hindu
Jain
Parsi / Zoroastrian
Rastafarian
Any other religion
Ex-British Armed Forces:
Please Select A Value...
Yes - ex services
No
Dependant of a ex-serving member
Unknown (Person asked and does not know or isn't sure)
Not stated (Person asked but declined to provide a response)
Do you have any Long Term Conditions?:*
Please Select A Value...
Yes
No
Don't Know/Not Sure
Do not wish to say
If yes please provide details:
Disability:
Please Select A Value...
No Disability
Behaviour and Emotional
Hearing
Manual Dexterity
Memory or ability to concentrate, learn or understand (Learning Disability)
Mobility and Gross Motor
Perception of Physical Danger
Personal, Self Care and Continence
Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits, etc)
Sight
Speech
Other
Do not wish to say
Are you pregnant or have a child under two years?:
Yes
No
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