Referral Form

Consent Details

Do you consent for Herefordshire and Worcestershire Health and Care Trust to store your information for the purposes of treatment?*

Yes

Do you consent for anonymised data to be passed to the Department of Health?*

Yes

Title*

First Name*

Middle Name 1

Middle Name 2

Last/Family Name*

Preferred Name

Previous Name

Gender*

Date of Birth*

Do you have a disability?*

Yes

No

Please only complete the next 2 questions if you have ticked 'Yes' for the above question.

What type of disability do you have?

Is there any other information we should know about your disability?

Address Line 1*

Address Line 2

Town/City*

County*

Postcode*

Home telephone number

Permission to leave voicemail

Yes

No

Mobile number*

Permission to leave voicemail*

Yes

No

Do you consent to be being contacted by SMS?*

Yes

No

Would you like to book your assessment through our online booking portal – if YES you will be sent an SMS to book the appointment. If NO you will be contacted by phone to book.*

Yes

No

Other telephone number

Permission to leave voicemail

Yes

No

Email*

Permission to send treatment questionnaires and letters by email*

Yes

No

Nationality*

Ethnicity*

Religion*

Can you speak English?*

Yes

No

Can you read English?*

Yes

No

Preferred Language*

Relationship status*

Sexuality*

Do you have a long term health condition?*

Yes

No

Please only complete this question if you have ticked 'Yes' for the above question.

What type of long term health condition do you have?

Smoking history:*

Smoker

Ex Smoker

Current non smoker but past smoking history

Never smoked tobacco

Do you need help with written or verbal communication?*

Yes

No

Please only complete the next 5 questions if you have ticked 'Yes' for the above question.

Type of support needed

Preferred contact method

Preferred information format

Professional help required

Is there any other information we should know about your communication needs?

Have you ever been a member of the Armed Services?*

If ‘Yes’ is the problem you want help with related to your time in the Armed Services?

Yes

No

Are you pregnant or have a child under one year?*

Yes

No

Do you work for the NHS in a frontline post (e.g. ambulance, A and E, intensive care ward, etc)?*

Yes

No

If 'Yes' is the problem you want help with related to your work with the NHS?

Yes

No

Do you work for Herefordshire and Worcestershire Health and Care Trust?*

Yes

No

GP name*

GP surgery*

Do you have children under the age of 18?*

Yes

No

In order for us to deliver services in a way which encourages a ‘think family’ approach, we need the details of your children under the age of 18 years. Please provide names and date of birth.

Are you a carer?*

Yes

No

In order for us to give you appropriate support, we need details of anybody you care for. Please provide name and date of birth and relationship to you.

Would you be happy to accept a short-notice cancellation appointment?*

Yes

No

Name*

Contact Telephone Number*

Please complete the captcha

Self Referral Form

Consent Details

Personal Details

Address Details

Contact Details

Demographic Details

Accessibility

Other Details

Emergency Contact/Next of Kin Details