Referral Form

Plymouth Options is for everyone aged sixteen or over, who live in Plymouth and are registered with a GP in the city.

Please select your GP practice:*

FOR PATIENT

You can self-refer to Plymouth by completing this secure form. The form takes up to 10 minutes to complete. If you do not have a mobile number please contact our service by calling 01752 435419 to complete your self-referral.

FOR GP/PROFESSIONAL

If you are a GP or health professional referring a patient, please complete the form and we will contact the patient within 5 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:

What is the main priority?:*

How is this effecting your day-to-day life? (e.g. work, relationships, social activities etc.)*

How long have you been experiencing these difficulties?* (weeks/months/years)

Have you ever had a mental health diagnosis, for example Bi-Polar, Personality disorder, Psychosis?*

Yes

No

If yes, please select diagnosis

Do you feel you are using alcohol or drugs to manage your mental health difficulties?*

Yes

No

Are you currently receiving support from any other services or professionals? (If so, please provide details)*

Title*

First Name*

Last Name*

Preferred Pronouns

Preferred Name

Date of Birth*

Address Line 1*

Address Line 2

Town/City

County

Postcode*

Gender*

Male

Female

Non-binary

I prefer not to say

Is gender the same as that assigned at birth?

We’d like to keep you updated about your care at every step.

Mobile phone number*

May we leave you a voice message?

Yes

No

Are we able to send text messages?*

Yes

No

Home phone number

Email Address

The NHS uses an encryption feature for all emails to correspond securely.

In the event of an emergency, please provide the details of someone who we can contact – ideally someone who lives nearby you.

First name*

Last name*

Phone number*

We ask these next questions to make sure we’re doing our best by reaching out to everyone in the community.

What is your ethnic group?*

What is your religion?*

What is your sexual orientation?*

Relationship Status*

We support people with a wide range of needs, and we’d like to be as helpful as possible.

Please provide us with any relevant details regarding disabilities (physical or learning) as well as long-term conditions (such as diabetes, heart disease, COPD) you may have*

Please let us know of any adjustments you may require

Are you an ex-British Armed Forces Veteran?*

Do you work for the NHS, are you a police officer or do you work in care?*

Are you currently pregnant, or do you have a baby under the age of 24 months?*

Yes

No

Would you like someone to provide sign language?*

Yes

No

If yes, please specify

British Sign Language

Makaton

Not Required

Would you like a language interpreter?*

Yes

No

If yes, please specify which language:

Do you require easy read material?*

Yes

No

Would you prefer to read things in large print?*

Yes

No

Please complete the captcha

Refer yourself

Reason for Referral

Tell us about you

How may we contact you?

Emergency contact

Additional details

How else could we help?