Talking Matters Warrington Self-Referral Form
Your Details
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
First Name:*
Last Name:*
Gender:*
Male
Female
Not known
Not specified
Is your gender the same as that assigned at birth?:*
Please Select A Value...
Yes
No
Not Known
Not Stated
Date of Birth:*
Address Line 1:*
Address Line 2:
Town/City:*
County:
Postcode:*
Accommodation Type:*
Please Select A Value...
Accommodation with Criminal Justice Support
Accommodation with mental health care support
Acute/long stay healthcare residential facility/hospital
Bail/Probation Hostel
Detention Centre
Extra Care Sheltered Housing
Foyer - accommodation for young people aged 16-25 who are homeless or in housing need
Homeless
Independent Hospital/Clinic
Mainstream Housing
Mental Health Registered Care Home
Mobile Accommodation
Night Shelter/Emergency Hostel/Direct Access Hostel
NHS Acute Psychiatric Ward
Non-Mental Health Registered Care Home
Nursing Home for older persons
Owner occupier
Placed in temporary accommodation by Local Authority (including Homelessness resettlement service) e.g. Bed and Breakfast accommodation
Prison
Tenant - Local Authority/Arms Length Management Organisation/Registered Landlord
Refuge
Rough Sleeper
Secure Psychiatric Unit
Settled mainstream housing with family/friends
Shared ownership scheme e.g. Social Homebuy Scheme (tenant purchase percentage of home value from landlord)
Sheltered Housing
Squatting
Sofa Surfing
Specialist Rehabilitation/Recovery
Staying with friends/family as a short term guest
Supported Accommodation (accommodation supported by staff or resident caretaker)
Supported Group Home (supported by staff or resident caretaker)
Supported Lodgings (lodgings supported by staff or resident caretaker)
Tenant - Housing Association
Tenant - Private Landlord
University or College accommodation
Young Offenders Institute
Not Known
Other
Preferred Phone Number:*
Preferred Phone Type:*
Please Select A Value...
Mobile Phone
Home Phone
Work Phone
Is it ok to leave a voice message on your preferred number?:*
Yes
No
Do you consent to receiving SMS?:
Yes
No
Other Phone Number:
Email address:*
We may need to email you some forms (Web-forms) to complete prior to any assessment with us.
Can we send you our web-forms:
Yes
No
Emergency Contact Details
Would you like to nominate an emergency contact?:*
Yes
No
If Yes, please complete the details below.
Full Name:
Telephone Number:
Relationship to you:
GP Practice Details
GP Surgery:*
Please Select A Value...
Birchwood Medical Centre
Brookfield Surgery
Causeway Medical Centre
Chapelford Medical Centre
Cockhedge Medical Centre
Culcheth Medical Centre
Dallam Lane Medical Centre
Eric Moore Partnership Medical Practice
Fairfield Surgery (278 Manchester Road)
Fearnhead Cross Medical Centre
Folly Lane Medical Centre
Greenbank Surgery (274 Manchester Road)
Guardian Medical Centre
Helsby Street Medical Centre
Holes Lane Surgery (28 Holes Lane)
Lakeside Surgery
Latchford Medical Centre
The Surgery (280 Manchester Road)
Padgate Medical Centre
Parkview Medical Practice
Penketh Health Centre
Springfields Medical Centre
Stockton Heath Medical Centre
Stretton Medical Centre
Westbrook Medical Centre
4 Seasons Medical Centre
If you are unable to find your GP Practice in the list, please contact your GP directly.
GP Telephone Number:
Preferred GP:
Do you have a disability?:*
Yes I have a disability
No I don’t feel I have a disability
I don’t want to say
If you selected yes, please provide details of your disability: this will enable the service to meet any access needs i.e. use of a lift, ensuring wheelchair access, access to BSL, hearing loop access etc.
Demographics
National identity:*
Please Select A Value...
British
English
Irish
Scottish
Welsh
Other
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
Religious Group:*
Please Select A Value...
No religious group or secular
Atheist / Agnostic
Church of England
Other protestant
Orthodox Christian
Roman Catholic
Other Christian
Muslim
Shi'ite Muslim
Sunni Muslim
Sikh
Jewish
Orthodox Jewish
Buddhist
Hindu
Jain
Parsi / Zoroastrian
Rastafarian
Any other religion
Not stated
Advaitin Hindu
Ahmadi
Amish
Anabaptist
Ancestral Worship
Anglican
Animist
Anthroposophist
Apostolic Pentecostalist
Armenian Catholic
Armenian Orthodox
Arya Samaj Hindu
Asatruar
Ashkenazi Jew
Atheist
Baha'i
Baptist
Black Magic
Brahma Kumari
Brethren
British Israelite
Bulgarian Orthodox
Calvinist
Catholic: Not Roman Catholic
Celtic Christian
Celtic Orthodox Christian
Celtic Pagan
Chinese Evangelical Christian
Chondogyo
Christadelphian
Christian Existentialist
Christian Humanist
Christian Scientists
Christian Spiritualist
Church in Wales
Church of God of Prophecy
Church of Ireland
Church of Scotland
Confucianist
Congregationalist
Coptic Orthodox
Deist
Druid
Druze
Eastern Catholic
Eastern Orthodox
Elim Pentecostalist
Ethiopian Orthodox
Evangelical Christian
Exclusive Brethren
Free Church
Free Church of Scotland
Free Evangelical Presbyterian
Free Methodist
Free Presbyterian
French Protestant
Goddess
Greek Catholic
Greek Orthodox
Haredi Jew
Hasidic Jew
Heathen
Humanist
Independent Methodist
Indian Orthodox
Infinite Way
Ismaili Muslim
Jehovah's Witness
Judaic Christian
Kabbalist
Liberal Jew
Lightworker
Lutheran
Mahayana Buddhist
Masorti Jew
Mennonite
Messianic Jew
Methodist
Moravian
Mormon
Native American Religion
Nazarene Church / SYN Nazarene
New Age Practitioner
New Kadampa Tradition Buddhist
New Testament Pentacostalist
Nichiren Buddhist
Nonconformist
Occultist
Old Catholic
Open Brethren
Pagan
Pantheist
Patient Religion Unknown (Where the PATIENT has not been asked for their RELIGIOUS OR OTHER BELIEF SYSTEM AFFILIATION)
Pentecostalist / SYN Pentacostal Christian
Peyotist
Plymouth Brethren
Presbyterian
Pure Land Buddhist
Quaker
Radha Soami / SYN Sant Mat
Reform Jew
Reformed Christian
Reformed Presbyterian
Reformed Protestant
Romanian Orthodox
Russian Orthodox
Salvation Army Member
Santeri
Satanist
Scientologist
Scottish Episcopalian
Secularist
Serbian Orthodox
Seventh Day Adventist
Shakti Hindu
Shaman
Shinto
Shiva Hindu
Shumei
Spiritualist
Swedenborgian / SYN Neo-Christian
Syrian Orthodox
Taoist
Theravada Buddhist
Tibetan Buddhist
Ukrainian Catholic
Ukrainian Orthodox
Uniate Catholic
Unitarian
Unitarian-Universalist
United Reform
Universalist
Vaishnava Hindu / Hare Krishna
Vodun
Wiccan
Yoruba
Zen Buddhist
Zwinglian
Are you able to communicate in spoken English?:*
Yes
No
Are you able to read and write in English?:*
Yes
No
Do you have another preferred Language: if so please select:
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
Are you able to read and write in your preferred language?:*
Yes
No
Do you require an Interpreter:*
Yes
No
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
Gay female
Gay male
Bisexual
Asexual
Other
Not stated
Not known
Unknown
Do you have any of the following Long Term conditions:
None
Asthma
Bi-polar
Cancer
Cardiac disorders
COPD
Dementia
Diabetes
Digestive tract conditions
Epilepsy
Fatigue/Chronic Pain
Musculoskeletal disorders
Post Covid 19 Syndrome
Respiratory
Schizophrenia
Skin conditions including eczema
Prefer not to say
Do you have a Medically-Unexplained Condition:
Chronic Fatigue Syndrome/ME
Irritable Bowel Syndrome with diarrhoea
Irritable Bowel Syndrome without diarrhoea
Medically Unexplained Symptoms (not specified)
None of these
Are you currently attending:*
Please Select A Value...
School
College
University
Other education establishment
None
Are you a Military Veteran whose current psychological difficulties are directly related to your military service?:*
Please Select A Value...
Yes - ex services
No
Dependant of a ex-serving member
Not stated (Person asked but declined to provide a response)
Unknown (Person asked and does not know or isn't sure)
If Yes, please provide Service Number:
Are you a parent with caring responsibilities for a child or children under 2, or are you or your partner currently pregnant:*
Yes
No
Are you a Frontline NHS or Health and Social Care member of Staff directly impacted by the Covid response?:*
Yes
No
Mental Health
Have you previously engaged with Secondary Care Mental Health Services? i.e. The Recovery Team, The Home Treatment Team, The Crisis Team, The Assessment Team (Wakefield House), Learning disability services, Dementia Services etc:*
Yes
No
If yes: Which service:
Are you currently receiving support or treatment from any of the above Secondary Care Mental Health Services?:*
Yes
No
If yes: Which service:
If you are currently open to Secondary Care Mental Health Services please liaise with the appropriate team. If therapy is agreed, shared care would need to be discussed and agreed between services.
Are you currently taking any medication for mental your health?:*
Yes
No
If yes, please list:
Please note Talking Matters Warrington is not a crisis intervention service
If you are in crisis or need immediate support please contact the 24/7 mental health crisis line on 0800 051 1508
You can find further information about our service on our website: https://www.mhm.org.uk/talkingmatters-warrington
You can also self-refer by calling the service on 01925 401720
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