Referral Form

Your Details

NHS Number if known

Title*

First Name*

Last Name*

Gender*

If 'Other' is selected, please specify

Date of Birth*

Address Line 1*

Address Line 2

Town/City*

County*

Postcode*

Permission to send written communication to your home?*

Yes

No

Mobile Phone Number*

Permission to leave voice messages*

Yes

No

Please note that Bedfordshire NHS Talking Therapies will be calling from a withheld/private number. We will only leave a message if you have given us permission to do so.

Permission to be contacted by text*

Yes

No

Please note that Bedfordshire NHS Talking Therapies use an electronic booking system, by giving permission you allow us to send you a link via text to book your appointment.

Other Phone Number

Email*

Permission to be contacted by email?*

Yes

No

Please share the details of someone we can contact in the event of an emergency. We would only ever contact this individual where we have concerns about yourself in order to help you find the correct immediate support and this is a requirement to be seen within our service.

First Name*

Last Name*

Telephone Number*

Relationship*

National Identity*

Ethnicity*

Religion*

Able to communicate in Spoken English?*

Yes

No

Understands written English?*

Yes

No

Prefer not to answer

Do you require an Interpreter/translator?*

Yes

No

Prefer not to answer

If yes, please specify which language

Preferred Language*

If other, please specify

Relationship Status*

Sexual Orientation*

Disability Status*

Do you have any long term medical conditions?

If other, please specify

Is your referral in relation to symptoms of covid/post covid syndrome?*

Yes

No

Prefer not to answer

Are you pregnant or do you have a child under 12 months?*

Yes

No

Prefer not to answer

Have you ever served in the British Armed Forces?*

If yes, please provide Service number

GP Practice*

By referring yourself to this service you are agreeing that the service may contact and share relevant information with your GP to facilitate your care.

We are always looking to enhance our service for future service users. Once you have completed your treatment would you consent for us to contact you by telephone and email to understand your experience and improve our service?

Yes

No

How did you hear about our service?*

Please complete the captcha

Self Referral Form

Your Details

Address

Contact Details

Emergency Contact Details

Demographics

Military Details

Registered GP Details