Referral Form

This information is kept on our electronic database strictly under the terms of data protection law and will not be shared with anyone outside the department. We collect this data purely for reporting purposes to ensure we are working as effectively as possible to enable all communities in Shropshire County to access our service.

NHS Number (if known):

Title:*

Given first name:*

Middle name:

Given last name:*

Preferred name:

Date of Birth:*

Gender:*

Is your gender identity the same as the gender you were given at birth?*

Yes

No

Prefer not to say

Preferred Pronouns

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Email:*

Are you happy to receive pre-appointment questionnaires via email?:*

Yes

No

Home Phone Number:

Permission to leave voicemail?:

Yes

No

Mobile Phone Number:*

Permission to leave voicemails?:*

Yes

No

Can we text you?:*

Yes

No

GP Surgery:*

Sexual Orientation:*

Religious or Belief affiliation:*

Ex British Armed Forces:*

Ethnicity:*

Interpreter Required?:*

Yes

No

If yes, please specify which language and dialect:

Can you read written English?*

Yes

No

Do you have a registered disability?*

Yes

No

If yes, please specify:

Do you have a long term health condition diagnosis?:*

If other, please specify:

Are you pregnant or the parent of child under one?:*

Yes

No

Are there any adjustments we could provide that would help you to access treatment, e.g difficulty with stairs or certain coloured paper or fonts?:

Are you in contact with any other Mental Health Services?:*

Yes

No

Any other relevant information:

By submitting this form, you confirm that you have read MPFT's Privacy Notice: *

Yes

https://www.mpft.nhs.uk/about-us/information-governance

I agree to my information being shared and gathered between services:*

Yes

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Shropshire, Telford and Wrekin NHS Talking Therapies

Self Referral Form

What we do with your information