Self Referral Form
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Mx
Dr
Prof
Rev
Lady
First Name:*
Last Name:*
Date of Birth:*
Gender:*
Male
Female
Trans Male
Trans Female
Indeterminate (unable to be classified as either male or female)
Prefer not to disclose/Not known
Ethnicity*
Please Select A Value...
White - White Any Other Background
White - White British
White - White Irish
White - White Polish
White - White Scottish
Asian or Asian British - Any other Asian background
Asian or Asian British - Bangladeshi
Asian or Asian British - Pakistani
Asian or Asian British - Indian
Asian or Asian British - Tamil
Black or Black British - Any other Black background
Black or Black British - African
Black or Black British - Caribbean
Mixed - Any other mixed background
Mixed - White and Asian
Mixed - White and Black African
Mixed - White and Black Caribbean
Other Ethnic Groups - Any other ethnic group
Other Ethnic Groups - Chinese
Not Stated - Not stated
Address Line 1:*
Postcode:*
Mobile Number:
May we leave a message on this number?
Yes
No
Would you like text reminders of appointments?
Yes
No
Home Number:
Email Address:*
GP Practice:*
Emergency Contact and Phone Number:*
Are you currently pregnant or do you have a child under 2 Years old?:*
Yes
No
Are you currently working with any other mental health services?:*
Yes
No
Do you have a long term condition that we need to be made aware of?:*
Yes
No
Not sure
If yes, please specify:
Asthma
Cancer
Chronic Fatigue Syndrome/Myalgic Encephalopathy (ME)
Chronic Obstructive Pulmonary Disease (COPD)
Chronic Pain, Fibromyalgia, MSK
Diabetes Type 1
Diabetes Type 2
Heart Related Condition/Cardiovascular (heart disease)
Irritable Bowel Syndrome
Long COVID (diagnosed only Post COVID 19 syndrome)
Medically Unexplained Symptom - diagnosed only eg. Functional Neurological Disorder
Neurological Condition eg. Epilepsy/Stroke/MS
Reproductive/Gynaecological Health eg. Menopause
LTC Other, please specify
Please tell us more about your long term health condition if you believe this is relevant to your mood and emotional wellbeing:
Do you have a probation officer allocated to you? *
Yes
No
If yes, please provide the following details of your probation officer so that we can obtain a risk assessment;
Probation Officer Name
Probation Officer Telephone Number
Probation Officer Location
How did you hear about the service?*
Please Select A Value...
Charity or community group
Council or government department e.g. Job Centre Plus
Event or training
GP
I have used NHS Talking Therapies before
Leaflet or poster
News article
NHS 111
NHS website
Other health or care professional
Radio or TV
School, college or university
Social Media
Web Search
Word of mouth
Other
If other, please specify
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