Sutton Uplift Self Referral Form
Brief questions to help understand the support that would suit you.
Please let us know if you want support to complete the form.
Contact Details
Title*
Please Select A Value...
Mr
Mrs
Miss
Ms
Mx
Dr
Rev
Prof
Other
First Name*
Last Name*
Date of Birth*
Address Line 1*
Address Line 2
Town/City
County
Postcode*
Email
Home Number
Can we leave a message on your home phone?
Yes
No
Mobile Number
Can we leave a message on your mobile?
Yes
No
Can we contact you via text?
Yes
No
SMS messages allow us to send you appointment reminders and service information via text message
Can we contact you via email?
Yes
No
Are you currently pregnant or have given birth in the last 12 months?
Currently Pregnant
Have given birth in last 12 months
Have you ever served in the Armed Forces? Or a relative of an ex/current Armed Forces member?
Please Select A Value...
Yes
Yes - ex services
No
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)
Your Support: Who supports you?
GP Name*
GP Surgery*
Family member / Friend
Do they live with you?
Yes
No
About You
This helps us to check if our service is reaching out to wide ranging people.
Gender*
Male
Female
Prefer not to say
Is this your birth gender?*
Yes
No
If No is selected, How do you identify? What is your preferred pro-noun?
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 - Tamil
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
Other Ethnic Groups - Eastern European
Not known - Not known
Not Stated - 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
Sexuality*
Please Select A Value...
Heterosexual
Lesbian or gay
Bisexual
Other
Unwilling to disclose
Marital Status
Please Select A Value...
Single
Married
Divorced
Widowed
Separated
Co-Habiting
Long term
Civil Partnership
Not Disclosed
Other
About Us - the services we provide include:
*Wellbeing - various workshops and practical 1-1 support to reduce stress or help you to access activities and services that improve your wellbeing (vocational, social, leisure or active opportunities, support groups)
*Psychological Therapies – various individual and group therapies for depression and anxiety based difficulties
*Psychiatric Assessments - for those with more serious mental health difficulties
Your Support Needs
Which of the services do you feel you need? (you can select both)*
Wellbeing Support
Talking (Psychological) Therapies for Anxiety & Depression (Employment support is also available for those in/awaiting treatment)
Not sure
Can you describe the main reason you have referred yourself to the service? Please add as much detail as possible so we can ensure you access the best support *
Do you require an interpreter?
Yes
No
If yes, please specify your 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
Romanian
Russian
Serbian/Croatian
Sinhala
Somali
Spanish
Swahili
Swedish
Sylheti
Tagalog (Filipino)
Tamil
Thai
Tigrinya
Turkish
Urdu
Vietnamese
Welsh
Yoruba
Other
Is there anything else we need to know in order to support you? (e.g. physical health issues or mobility issues, hearing difficulties, visual impairment, learning difficulties, travel, concerns regarding your safety, relative / friend speak on your behalf – please provide the name)
Do you have any diagnosed mental health conditions?
Are you being seen by another service?
Yes
No
If YES please give details:
Do you have any physical health conditions? Please specify:
Could you explain your symptoms?
Does this impact on your emotional health?
Yes
No
If YES, describe this impact?
How did you hear about Uplift?
Please Select A Value...
Advert
CAB
Website/internet
Used before
Word of mouth
Local charity
Community venues
Community event
Faith organisation
Employer/College
Social Services
Other health services
Job Centre
In order to reduce waiting times and ensure timely assessment and treatment, we work closely in partnership with digital providers. These providers are currently Xyla digital therapies, IESO and Silver Cloud.
Do you consent to sharing your information and being contacted by these services if appropriate?*
Yes
No
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