Shropshire Primary Care Psychological Therapies Service Self Referral Registration 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.
Self Referral Form
NHS Number (if known):
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Mx
Dr
Rev
Professor
Given first name:*
Middle name:
Given last name:*
Preferred name:
Date of Birth:*
Gender:*
Male
Female
Non binary
In another way
Prefer not to say
Is your gender identity the same as the gender you were given at birth?*
Yes
No
Preferred Pronouns
Please Select A Value...
She/Her/Her
He/Him/His
They/Them/Their
Ae/Aer/Aer
Ey/Em/Eir
Fae/Faer/Faer
Per/Per/Pers
Ve/Ver/Vers
Xe/Xem/Xyr
Ze/Hir/Hir
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:*
Please Select A Value...
Heterosexual / Straight
Lesbian or gay
Bisexual
Other
Prefer not to say
Religious or Belief affiliation:*
Please Select A Value...
Atheist / Agnostic
Baha'i
Buddhist
Church of England
Hindu
Jain
Jewish
Muslim
Orthodox Jewish
Pagan
Roman Catholic
Sikh
No religious group or secular
Not stated
Ex British Armed Forces:*
Please Select A Value...
Yes - ex services
No
Dependant of a ex-serving member
Unknown (Person asked and does not know or isn't sure)
Not stated (Person asked but declined to provide a response)
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
Black or Black British - African
Black or Black British - Caribbean
Black or Black British - Any other Black background
Asian or Asian British - Any other Asian background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
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?:*
None
Asthma
Cancer
Chronic Pain
COPD
Diabetes
Epilepsy
Heart Disease
Long covid
Medically Unexplained Conditions
Musculoskeletal eg Fibromyalgia, Osteo arthritis
Other respiratory disease
Other
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:
What we do with your 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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