Self Referral Form
If you need immediate support please call your GP or go to your local Accident & Emergency department.
Please provide as much information as possible so we can process your referral efficiently. If you are unsure if our service is the right service for you or if you have any problems completing this online form, you can call us to discuss this.
Your Details
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
First Name:*
Last Name:*
You can only refer yourself to us if you are over 18
Date of Birth:*
Gender:*
Male
Female
Transgender female
Transgender male
Gender non-binary
Gender-fluid/gender-queer
Intersex
Other
Not known
Not specified
Address Line 1:*
Address Line 2:
Town:*
County:*
Postcode:*
Telephone Number:*
Can we leave voicemails on this number?:*
Yes
No
Other Number:
Can we leave voicemails on this number?:
Yes
No
Can we contact you via SMS?
Yes
No
Email:
By providing us with this information we will assume that you consent to be contacted in this way.
Preferred methods of communication:
Post
Phone
Email
SMS
Do you need an interpreter?:*
Yes
No
If yes, please specify your 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
GP Details
We ask for your GP details so we can contact them about your care if needed. Where possible we will discuss this with you first. We only see people with a GP in Kingston.
Do you have a GP in Kingston?*
Yes
GP Practice:*
Please select here if you do not wish us to inform your GP:
Do not inform my GP
COVID-19
During the pandemic we are providing additional support for people experiencing distress or anxiety relating to COVID-19. We are also offering priority support to front-line staff and key workers.
If you are referring due to distress or anxiety related to COVID-19 please tick here:
Yes
Please indicate if you are any of the following:
Front-line staff working with patients experiencing COVID-19 (e.g. doctor, nurse, care assistant etc)
Key worker (e.g. pharmacist, teacher, social worker, police etc)
Vulnerable/shielding
Further Information
We ask these questions to ensure that our service is being accessed by everyone and to ensure any specific requirements are met.
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
Sexuality:*
Please Select A Value...
Heterosexual
Gay/Lesbian
Bisexual
Other
Not stated
Not known
Unknown
Do you have any long term medical conditions?:
Diabetes
Chronic Obstructive Pulmonary Disease (COPD)
Asthma
Other Respiratory Disease
Heart disease
Cancer
Musculoskeletal Disorder (MSK)
Chronic pain, including fibromyalgia
Epilepsy
Skin condition including Eczema
Digestive tract conditions
Other
Do you have any specific needs you would like us to be aware of e.g. a disability?:
Are you pregnant or do you have any children under 1 or under 5?:
Pregnant
Children under 1
Children aged 1-5
Are you an ex-British Armed Forces member?:*
Please Select A Value...
Yes
No
Have you received in the past, or are you currently receiving counselling, therapy or other mental health support elsewhere?:*
Yes
No
Unsure
If yes, please provide further details:
Please provide brief details of your problem or what you would like us to help you with:*
Would you prefer to have all of your contact with our service online if this is available? (this may include online therapy programmes, communication with your therapist online or video sessions):*
Yes
No
Maybe
Where did you hear about us?*
Please Select A Value...
GP
Another health service or health professional
Friend of family member
Social media (eg twitter, facebook)
Internet search engine (eg google)
Community centre
Library
Job centre or employment support service
University
Other
If other, please specify:
Thank you for taking the time to complete this form. We hope to be in touch with you within two working days. We may contact you by email - emails can sometimes go into junk folders so please check this.
Please be aware that if you report that you (or others) are at risk of harm or self-harm, or if you indicate that you may commit a crime, it is likely that we would have to inform other services for your own welfare and the welfare of others. We would always try to contact you first before making this decision.
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