Webinar Referral Form
Bedfordshire NHS Talking Therapies is a Primary Care Service for mild to moderate mental health issues.
These Webinars are run by Bedfordshire NHS Talking Therapies for the residents of Bedfordshire, Luton and Milton Keynes. By completing this form you are agreeing to be contacted by Bedfordshire NHS Talking Therapies.
If you are in Crisis and need immediate help to keep yourself or others safe please call the Emergency Services on 999
Registration Details
Title*
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
First Name*
Last Name*
Gender*
Male
Female
Other
If other, please specify your gender here:
Date of Birth*
NHS Number
Address Line 1*
Address Line 2
Town/City*
County*
Postcode*
Permission to send written communication to home address?*
Yes
No
Mobile Phone Number*
Please note calls may come from a withheld number.
Permission to leave voice message?*
Yes
No
Permission to be contacted by Text?*
Yes
No
Home Phone Number
Email Address*
Please Note all Webinar links are sent via Email.
Permission to be contacted via Email?*
Yes
No
Further Information
National Identity*
Please Select A Value...
American
Australian
Bangladeshi
British
English
French
German
Indian
Irish
Italian
Pakistani
Polish
Portugal
Scottish
South African
Sri Lankan
Turkish
Welsh
Zimbabwean
Other
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 - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
Are you able to read and write in English?*
Yes
No
Preferred Language*
Please Select A Value...
Akan (Ashanti)
Albanian
Amharic
Arabic
Bengali & Sylheti
Brawa & Somali
British Signing Language
Cantonese
Cantonese and Vietnamese
Creole
Dutch
English
Ethiopian
Farsi (Persian)
Finnish
Flemish
French
French creole
Gaelic
German
Greek
Gujarati
Hakka
Hausa
Hebrew
Hindi
Igbo (Ibo)
Italian
Japanese
Korean
Kurdish
Lingala
Luganda
Makaton (sign language)
Malayalam
Mandarin
Norwegian
Pashto (Pushtoo)
Patois
Polish
Portuguese
Punjabi
Russian
Serbian/Croatian
Sinhala
Somali
Spanish
Swahili
Swedish
Sylheti
Tagalog (Filipino)
Tamil
Thai
Tigrinya
Turkish
Urdu
Vietnamese
Welsh
Yoruba
Other
Interpreter Required*
Yes
No
Relationship Status*
Please Select A Value...
Single
Married
Divorced
Widowed
Separated
Co-Habiting
Long term
Civil Partnership
Not Disclosed
Sexuality*
Please Select A Value...
Heterosexual
Lesbian or gay
Bisexual
Other
Not known
Not stated
Disability Status*
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
Have you ever served for the British Armed Forces?*
Please Select A Value...
Yes - ex services
No
Are you currently pregnant or have a child under 12 months of age?
Yes
No
How did you hear about our service?*
GP Details
GP Name
GP Surgery*
Webinar Programme
Please select the Webinar your wish to attend
Coping with Long Term Conditions in Times of Uncertainty
Stress Management
Improving Sleep
Balancing my Thoughts
Improving Motivation
Managing Worries
Fatherhood and Low Mood
Men’s Mental Health
Pregnancy and New Motherhood
Other - Please specify below
If other, please specify
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