Self Referral Form
Your Details
NHS Number if known
Title*
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
First Name*
Last Name*
Gender*
Male
Female
Non-Binary
Not specified
Not known
Other
If 'Other' is selected, please specify
Date of Birth*
Address
Address Line 1*
Address Line 2
Town/City*
County*
Postcode*
Permission to send written communication to your home?*
Yes
No
Contact Details
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
Emergency Contact Details
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*
Please Select A Value...
Next of Kin
Family
Friend
Work
GP
Social Worker
Health Visitor
Midwife
Housing Officer
Mental Health Worker
Carer
Demographics
National Identity*
Please Select A Value...
English
Scottish
Welsh
Irish
British
Other
American
Australian
Bangladeshi
French
German
Indian
Italian
Pakistani
Polish
Portugal
South African
Sri Lankan
Turkish
Zimbabwean
Prefer not to answer
Ethnicity*
Please Select A Value...
White - British
White - Irish
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed 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 - Caribbean
Black or Black British - African
Black or Black British - Any other Black background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
Not known - Prefer Not to Say
Religion*
Please Select A Value...
Baha'i
Buddhist
Christian
Hindu
Jain
Jewish
Muslim
Pagan
Sikh
Zoroastrian
Other
None
Patient Religion Unknown
Prefer Not To Say
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
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
Preferred 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
If other, please specify
Relationship Status*
Please Select A Value...
Single
Married
Divorced
Widowed
Separated
Co-Habiting
Long term
Civil Partnership
Not Disclosed
Sexual Orientation*
Please Select A Value...
Heterosexual
Lesbian or gay
Bisexual
Other
Not known
Prefer Not to Say
Disability Status*
Please Select A Value...
Has Disability
No Perceived Disability
Not Stated
Prefer not to answer
Do you have any long term medical conditions?
Asthma
Cancer
Chronic Fatigue
Chronic Kidney Disease
Chronic Muscular Skeletal
Chronic Obstructive Pulmonary Disease
Chronic Pain
Chronic Pain and Fibromyalgia
Coronary Heart Disease
Dementia
Diabetes
Epilepsy
Heart Failure
Hypertension
Insulin Dependent Diabetes Mellitus
Medically Unexplained Conditions
Multiple Sclerosis
Non Insulin Dependent Diabetes Mellitus
Parkinsons Disease
Severe Mental Health Problems
Stroke and Transient Ischaemic Attack
Symptoms of covid/post covid syndrome
Other
Prefer not to answer
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
Military Details
Have you ever served in the British Armed Forces?*
Please Select A Value...
Yes - ex services
No
Dependant of a ex-serving member
Not stated (Person asked but declined to provide a response)
If yes, please provide Service number
Registered GP Details
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 Select A Value...
Active Signposting
GP
Facebook Advert
Leaflet Drop
Marketing
Other Professional
Outreach Group
Re-engagement
Webinar
Website
Word of Mouth
Please complete the captcha
Submit
Cancel