Self Referral Form
Welcome to the HUB. Please note, by submitting this self-referral form, you are consenting to us confidentially storing your personal data.
Title:*
Please Select A Value...
Dr
Miss
Mr
Mrs
Ms
Prof
Rev
First Name:*
Last Name:*
Gender:*
Male
Female
Not known
Not specified
Date of Birth:*
Address Line 1:*
Address Line 2:
Town/City:*
Postcode:*
Home Phone Number:
Mobile Phone Number:
Permission to receive texts:
Yes
No
Permission to leave voicemail:
Yes
No
Permission to be contacted by email:
Yes
No
Email address:
Ethnicity:*
Please Select A Value...
White - British
White - Irish
White - Any other White background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Any other Asian background
Black or Black British - African
Black or Black British - Caribbean
Black or Black British - Any other Black background
Mixed - White and Asian
Mixed - White and Black African
Mixed - White and Black Caribbean
Mixed - Any other mixed background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not known - Not known
Not Stated - Prefer not to say
Sexuality:*
Please Select A Value...
Heterosexual
Bisexual
Lesbian or gay
Other
Not known
Prefer not to say
Disability Status:*
Has Disability
No Perceived Disability
Prefer not to say
Currently off work due to stress/emotional ill health?:*
Yes
No
Prefer not to say
Are you seeing any of the following?:*
Adult Mental Health Teams
Secondary Care
IPU3-8
None
Would you like to say why you have contacted the With Staff In Mind Hub?:
Where did you hear about the service?:
Please Select A Value...
Outreach session
Friend/colleague
Leaflet/poster
Search Engine/Website
Other
What are your preferred days/times for your initial assessment appointment?:
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