Self referral form | | Patient Portal

Title *

First name *

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Middle Name

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Last name *

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Previous Name(s) *

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What is your date of birth? *

Address - line 1 *

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Address - line 2 *

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Address - line 3

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Address - parish *

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Post code *

Preferred Phone Number *

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Can we leave a message on your preferred telephone number? *

No

Yes

Home phone

Can we leave a message on your home phone?

No

Yes

Email address (first contact will be via email. By submitting your email, we assume you consent to us emailing you unencrypted. If you do not submit your email address, we will contact you by post) *

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Mobile phone number *

First contact will be via text message due to our ‘Choose and Book’ online booking system.

By submitting your mobile number, we assume you consent to us messaging you via text message. If you do not submit a mobile number, we will contact you by post

Can we leave a message on your mobile phone?

No

Yes

Do you consent to receive appointments via text message *

Yes

No

Is an interpreter required? *

No

Yes

Please select your ethnicity

Please select your gender *

Please select your first language *

Please select your GP surgery *

Please enter your GP name

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Are you a current healthcare or key worker?

Yes

No

Are you a current or previous member of the military services?

Current medication prescribed for anxiety and/or depression:

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Reason for referral: please describe the current difficulties you wish to focus on. *

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Are you expecting a child or have a child under 24 months? *

If yes, do you consent to us contacting your midwife or health visitor?

How long have you experienced these difficulties? *

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What are the goals you would like to achieve by engaging with our service? *

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Please select your working situation *

Are you currently signed off sick by your doctor? *

Yes

No

If yes, for how long/until when?

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Are you in receipt of any benefits? *

Yes

No

If yes, please specify:

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Do you use alcohol or recreational drugs to help you cope with your problems? *

Yes

No

If yes, please tell us a bit more:

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Have you ever been diagnosed with a mental health problem? *

Yes

No

If yes, what was your diagnosis?

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Have you received any psychological therapy? *

Yes

No

When? With whom?

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Have you ever self-harmed or attempted to take your own life? *

Yes

No

If yes, approximately, when was this? Please tell us a bit more:

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Do you have any special needs we need to consider? *

Yes

No

If yes, please tell us a bit more:

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Healthy Minds - Guernsey