Referral Form - Self Help

Your service

Which service you would like to access?

Your details

First Name*

Last Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Gender*

Male
Female
Prefer not to say

NHS Number

We really need this, if possible. You can find your NHS number on:
• A medical card
• A letter from your GP or a hospital
• A printed prescription

How we contact you

Landline number

Mobile number

We will try to contact you by telephone unless otherwise advised. If possible, please provide a mobile number in addition to a landline.

Email Address

Getting in touch with you

Please tick A, B or C if you give permission for us to:

A) Leave a message with someone answering my phone
B) Leave a message on my answering machine
C) Send reminders via text message to your mobile
D) send a message via email

Your GP's details

GP details*

We are required to notify your GP that you are accessing our service. Please provide permission for us to write to your GP with this information. Unfortunately if your GP is not listed in the drop down we are unable to offer you support via our service. Please search NHS choices for your local IAPT provider.

Do you give Self Help Services permission to contact your GP?*

We are required to notify your GP that you are accessing our service. Please provide permission for us to write to your GP with this information. Please note that if you do not give permission we are unable to offer you this service.

Yes, I give you permission to contact my GP
No, I don't give you permission to contact my GP

Presenting Problem

Please provide a brief summary of your problem

Are you experiencing any issues related to the below. Please tick where appropriate.

Domestic abuse
Housing
Isolation
Work-related

About you

What is your marital status?

White

British
Irish
Any other white background

Mixed

White and Black Caribbean
White and Black African
White and Asian
Any other mixed background

Asian or Asian British

Indian
Pakistani
Bangladeshi
Any other Asian background

Black or Black British

Caribbean
African
Any other black background

Chinese or other ethnic group

Chinese
Any other

What is your religion?

Is English your first language?

Yes
No

If no, please give details

Do you have any problems speaking, reading or writing English?

Yes
No

If yes, please give details

Do you have any disabilities we should be aware of?

Yes
No

If yes, please give details

Do you have any long term health conditions?

Yes
No

If yes, please give details; e.g. visual, speech, hearing, mobility.

Have you served in the Armed Forces?*

Yes
No

If yes, please give details.

Are you or your partner currently pregnant; or had a baby in the last 2 years?*

Yes
No

If yes, please give details.

Where did you hear about the service?