Online Self Referral Form
Your Details
NHS Number (if known):
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
Not known
First Name(s):*
Surname:*
Date of Birth:*
Gender:*
Male
Female
Not known
Not specified
Address Line 1:*
Address Line 2:
Town/City:*
County:*
Postcode:*
Email:*
Can we contact you via e-mail?:*
Yes
No
Mobile Number:
Can we leave voicemails?:
Yes
No
Can we send this number texts?:
Yes
No
Home Number:
Can we leave voicemails?:
Yes
No
Work Number:
Can we leave voicemails?:
Yes
No
GP Details
GP Surgery name:*
Named GP (if known):
Do you give us consent to contact your GP?:*
Yes
No
We will always contact your GP if we need to keep you or others safe.
Further Details
Language:
Please Select A Value...
Akan (Ashanti)
Albanian
Amharic
Arabic
Bengali & Sylheti
Brawa & Somali
British Sign 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 communicate in English?:
Yes
No
Please detail any Language, Religious, Mobility or other requirements: (e.g. wheelchair access or an interpreter required):
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
Sexual orientation:*
Please Select A Value...
Heterosexual
Lesbian or gay
Bisexual
Other
Not known
Not stated
Unknown
Do you have any of the following Long term Health Conditions?:
No
Asthma
Cancer
Chronic Fatigue
Chronic Muscular Skeletal
Chronic Obstructive Pulmonary Disease
Chronic Pain
Coronary Heart Disease
Eating Disorder
Epilepsy
Fibromyalgia
Hypertension
Insulin Dependent Diabetes Mellitus
Non Insulin Dependent Diabetes Mellitus
Irritable Bowel Syndrome
Parkinson's Disease
Other
If Other, please state:
Ex-British Armed Forces or dependant of an ex-serving member?:*
Please Select A Value...
Dependant of an Ex-member
No (None of the above)
Not stated (Person asked but declined to provide a response)
Ex - member
Reservist
Ex - reservist
Currently serving
Dependant of a currently serving member
Don't Know
Are you a carer for anybody with the following difficulties?:
No
Asthma
Cancer
Chronic Pain
COPD
Dementia
Diabetes
Epilepsy
Heart Failure
Learning Disability
Mental Health Difficulty
Medically Unexplained Conditions
Other
Do you have any of the following disabilities?:
No Disability
Behaviour and Emotional
Hearing
Manual Dexterity
Memory or ability to concentrate, learn or understand (Learning Disability)
Mobility and Gross Motor
Perception of Physical Danger
Personal, Self Care and Continence
Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits etc)
Sight
Speech
Other
Do not wish to say
Religious or Belief Affiliation:
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
Zoroastrian
Rastafarian
Any other religion
Not stated
Referral Information
Please use this space to tell us a little about what you'd like help with:*
Are you receiving any current support for your mental health?:*
Yes
No
If Yes, please give details:
Are you currently taking any prescribed medication?:*
Yes
No
If Yes, please give details:
If you wish to attend a psycho-educational course, please provide the details of location, day and time:
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