Register To Our Service Online
Please complete this form if you would like help from our service. Our NHS-funded therapies are for people aged 16+ who are registered with a GP Practice in Cornwall & the Isles of Scilly.
When you submit this form, a member of our team will make contact within five working days to arrange an appointment.
If you are a GP or health professional referring a patient, please complete the form and we will contact the patient within five working days. If we cannot contact the patient, we will inform you within 15 working days.
Please indicate if you are referring yourself or a patient:*
I am referring myself
I am a GP or health professional referring a patient
If you are a GP or health professional, please provide your name, role and contact details:
Personal Details
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
First Name:*
Preferred Name:
Surname:*
Date of Birth:*
Gender identity:*
Male
Female
Not specified
Not known
Address line one:*
Address line two:
Town:*
County:*
Postcode:*
Please select the times when we can best reach you by phone to arrange an appointment. We will be calling from a withheld number and will only speak to you/the patient (unless you give permission to speak with anybody else):*
8.30am-9am
9am-1pm
1pm-5pm
5pm-6.30pm
Any of the above
Cannot be contacted by phone, please email
Cannot be contacted by phone, please send a letter
If someone else answers can we leave a message with them and disclose where we are calling from?:*
Yes
No
If yes, please give their name(s):
Landline phone number (leave blank if not applicable):
Landline phone number type:
Please Select A Value...
Home Phone
Work Phone
Other Phone
Is it ok to leave a voicemail message?:
Yes
No
Mobile Number:
Is it ok to leave a voicemail message?:
Yes
No
Can we send you SMS text messages?:
Yes
No
Email:*
Confirm Email:*
We routinely provide questionnaires by email for you to complete before your appointment.
If you are unable to receive questionnaires by email, please indicate here:
I am unable to receive questionnaires by email
GP Details
Registered GP surgery:*
GP Name (if known):
GP Surgery Address (if known):
Referral Information
Please be aware that we are not an emergency service. If you feel that you are in crisis or in need of more urgent support, please contact your GP or the Community Mental Health Team on 0845 207 7711.
Out of hours crisis numbers;
- Nightlink - Freephone 0808 8000 306
- Samaritans - Freephone 116 123
Please provide a brief description of the current difficulties you are experiencing that you would like to address.
Reason(s) for referral:*
Are you currently involved with the Community Mental Health Team (CMHT)? Or have been involved within the last year?:*
Please Select A Value...
Yes, currently involved with CMHT
Yes, only within the last year
No
I don't know
Prefer not to say
If yes, to ensure you receive the right level of care for your needs, do we have permission to liaise and request information from the Cornwall Foundation Trust?:
Please Select A Value...
Yes
No
Unsure
Further Information
Do you need any assistance from a translator to access our service?:*
Yes
No
Do you have any disabilities?:*
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
Is there any way in which we can personalise our service for you to make the experience easier? e.g. forms in large print, wheelchair access etc.:
Do you have any long term medical conditions?:*
Please Select A Value...
Yes
No
Prefer not to say
Long Term medical condition(s):
COPD (Chronic Obstructive Pulmonary Disease)
Coronary heart disease/Cardiovascular disease
Diabetes
Cancer
Chronic Fatigue/ME
Chronic Pain
Dementia
Epilepsy
Heart Failure
Medically Unexplained Conditions
Rheumatoid Arthiritis
Stroke/Cerebrovascular disease
Other (Severe Asthma, Sickle Cell anaemia, Parkinsons, Arthritis, MS etc.)
Ethnicity:*
Please Select A Value...
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 - African
Black or Black British - Caribbean
Black or Black British - Any other Black background
White - British
White - Irish
White - Any other White 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
Not known - Not known
Not Stated - Not Stated
National Identity:*
Please Select A Value...
English
Cornish
British
Welsh
Irish
Scottish
Other
If Other, please specify:
Religion/Belief:*
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
Not stated
Advaitin Hindu
Ahmadi
Amish
Anabaptist
Ancestral Worship
Anglican
Animist
Anthroposophist
Apostolic Pentecostalist
Armenian Catholic
Armenian Orthodox
Arya Samaj Hindu
Asatruar
Ashkenazi Jew
Atheist
Baha'i
Baptist
Black Magic
Brahma Kumari
Brethren
British Israelite
Bulgarian Orthodox
Calvinist
Catholic: Not Roman Catholic
Celtic Christian
Celtic Orthodox Christian
Celtic Pagan
Chinese Evangelical Christian
Chondogyo
Christadelphian
Christian Existentialist
Christian Humanist
Christian Scientists
Christian Spiritualist
Church in Wales
Church of God of Prophecy
Church of Ireland
Church of Scotland
Confucianist
Congregationalist
Coptic Orthodox
Deist
Druid
Druze
Eastern Catholic
Eastern Orthodox
Elim Pentecostalist
Ethiopian Orthodox
Evangelical Christian
Exclusive Brethren
Free Church
Free Church of Scotland
Free Evangelical Presbyterian
Free Methodist
Free Presbyterian
French Protestant
Goddess
Greek Catholic
Greek Orthodox
Haredi Jew
Hasidic Jew
Heathen
Humanist
Independent Methodist
Indian Orthodox
Infinite Way
Ismaili Muslim
Jehovah's Witness
Judaic Christian
Kabbalist
Liberal Jew
Lightworker
Lutheran
Mahayana Buddhist
Masorti Jew
Mennonite
Messianic Jew
Methodist
Moravian
Mormon
Native American Religion
Nazarene Church / SYN Nazarene
New Age Practitioner
New Kadampa Tradition Buddhist
New Testament Pentacostalist
Nichiren Buddhist
Nonconformist
Occultist
Old Catholic
Open Brethren
Pagan
Pantheist
Pentecostalist / SYN Pentacostal Christian
Peyotist
Plymouth Brethren
Presbyterian
Pure Land Buddhist
Quaker
Radha Soami / SYN Sant Mat
Reform Jew
Reformed Christian
Reformed Presbyterian
Reformed Protestant
Romanian Orthodox
Russian Orthodox
Salvation Army Member
Santeri
Satanist
Scientologist
Scottish Episcopalian
Secularist
Serbian Orthodox
Seventh Day Adventist
Shakti Hindu
Shaman
Shinto
Shiva Hindu
Shumei
Spiritualist
Swedenborgian / SYN Neo-Christian
Syrian Orthodox
Taoist
Theravada Buddhist
Tibetan Buddhist
Ukrainian Catholic
Ukrainian Orthodox
Uniate Catholic
Unitarian
Unitarian-Universalist
United Reform
Universalist
Vaishnava Hindu / Hare Krishna
Vodun
Wiccan
Yoruba
Zen Buddhist
Zwinglian
Sexual Orientation:*
Please Select A Value...
Heterosexual
Lesbian or gay
Bisexual
Other
Not known
Relationship Status:*
Please Select A Value...
Single
Married
Divorced
Widowed
Separated
Co-Habiting
Long term
Civil Partnership
Not Disclosed
British Armed Forces:*
Please Select A Value...
No
Yes - currently serving
Yes - ex services
Dependant of a ex-serving member
Dependant of currently serving member
Unknown (Person asked and does not know or isn't sure)
Are you or have you been pregnant or had a baby in the last 12 months?:
Please Select A Value...
Yes
No
Prefer not to say
Are you a mum with a child under 3 years old?:
Please Select A Value...
Yes
No
Prefer not to say
How did you become aware of Outlook South West?:*
Please Select A Value...
Doctor / GP Surgery
Other healthcare professional
Friend or family member
Local radio
Local Newspaper
Cornwall College Campus
Internet search
Outlook Facebook page
Posters or Leaflets
Previously had treatment with Outlook
Other
Use of Information
By submitting this online referral form, you are agreeing to share your data with the NHS. For more information on how we collect, store and use your data – please see www.outlooksw.co.uk/use-personal-information
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