Self Referral Form
Please complete all questions below - Your referral may not be processed until all the necessary information has been received.
If you need help completing this form, please email info@mindinbexley.org.uk giving your name and telephone number - a staff member will then call you within a few days to help complete the form.
Your Personal Details
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
First Name:*
Surname:*
Date of Birth:*
Gender:*
Male
Female
Non-binary
Indeterminate (unable to be classified as either male or female)
Not known
Not Stated
Other - not listed
Sexuality:*
Please Select A Value...
Heterosexual
Lesbian or gay
Bisexual
Other
Not stated
Not known
Unknown
Relationship Status:*
Please Select A Value...
Single
Married
Divorced
Widowed
Separated
Co-Habiting
Long term
Civil Partnership
Not Disclosed
Address Line 1:*
Address Line 2:
Town/City:*
County:*
Postcode:*
Landline Number:
Can we leave a voicemail on this number?:
Yes
No
Mobile Number:
Can we leave a voicemail on this number?:
Yes
No
Can we contact you by SMS?:
Yes
No
Email:*
Please write your email address again:*
GP Name and Practice:*
NHS Number:
Are you currently pregnant?:*
Yes
No
Is your partner currently pregnant?:*
Yes
No
Are you a parent of a baby under 12 months?:*
Yes
No
First 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
Religion/Faith:*
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
Interpreter Required?:*
Yes
No
If yes, what language?:
Next of kin name:*
Next of kin relationship to you:*
Next of kin phone number:*
Special needs or adjustments:* (for example, you are a wheelchair user)
What is your ethnicity?:*
Please Select A Value...
Asian or Asian British - Any other Asian background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Black or Black British - African
Black or Black British - Any other Black background
Black or Black British - Caribbean
White - British
White - Irish
White - Any other White background
Mixed - White and Asian
Mixed - Any other mixed background
Mixed - White and Black African
Mixed - White and Black Caribbean
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
Do you have a registered disability?:*
Yes
No
If Yes, please specify:
Behaviour and Emotional
Hearing
Manual Dexterity
Memory or ability to concentrate, learn or understand (Learning Disability)
Mobility and Gross Motor
Other
Perception of Physical Danger
Personal, Self Care and Continence
Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits etc)
Sight
Speech
If Other, please specify:
Any other health details which are important for us to know?:*
FURTHER INFORMATION
Have you ever received treatment (CBT/Counselling/other) for your mental health?:*
Yes
No
If yes, please provide details to include when, where and whether this was helpful:
Have you ever received a mental health diagnosis?:*
Yes
No
If yes, please provide details to include where and when you were diagnosed and what the diagnosis is:
Are you currently on a waiting list or receiving therapy from another mental health provider such as Oxleas?:*
Yes
No
If yes, please provide details:
Services required?:*
Crisis Cafe
Digital Hub
Employment Support for individuals with mental health issues
Recovery College and Workshops
Support if you are caring for a friend/relative with mental ill health
Talking Therapies
Please provide a reason for your referral, and what you would like support with?:*
SERVICE INFORMATION
We use your phone number to call and text you about appointment information. We use your email address to contact you about your referral and also to seek feedback while you are engaging with our service or shortly afterwards. Therapists may also use your email address to contact you about appointments and send you resources. Please make sure you have written it accurately on the first page of this form.
People have told us that emails from us sometimes go into their spam folders. Please check these folders in your email account to ensure that you haven’t missed correspondence from us.
Please select to confirm that we are able to contact you by:*
Phone
Text
Email
Letter
None of the above
If we are unable to reach you, can we leave a message?:*
Yes
No
Information you share with us is confidential between you, our service and your GP. The only time we will break this confidentiality is if we are concerned that there is a serious risk of harm to you or someone else. We store information on our IT system. This is confidential, and cannot be accessed by anyone outside of our service. We do share anonymous information with NHS England and other statutory bodies that monitor our performance. This information may include details on the number of people we see, what type of treatment they receive, or if they recovered. This does not include your name, address, contact details etc.
Please confirm you understand and agree to the above:*
Yes
If we think your needs are better met by another service, we would normally share your information in order to make a referral. Are you happy with this?:*
Yes
No
Where did you hear about us?:*
Please Select A Value...
GP recommended
Healthcare Professional (not GP)
Friends or Family
Social Media (e.g. Facebook, Instagram)
Poster or Leaflet
Internet Search Engine
Other
Thank you for completing the above information, you will be contacted in due course.
Please complete the captcha
Submit
Cancel