Self referral form | Stockport Child Self Help Professional Referral Form

Client/Patient Contact Information

Title *

First Name *

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Last Name *

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Address Line 1 *

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Address Line 2

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Address Line 3

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Town/City *

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County

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Post Code *

Does the client provide consent for us to send correspondence to this address? *

Yes

No

Date of Birth *

Gender Identity *

Is your gender the same as your gender assigned at birth? *

NHS Number

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

Mobile Phone Number

Does the client provide consent for us to contact them on this number? *

Yes

No

Home Phone Number

Does the client provide consent for us to contact them on this number? *

Yes

No

Email Address *

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Does client give: Consent to leave a voicemail on their home phone number? *

Yes

No

Does client give: Consent to leave a voicemail on their mobile phone number? *

Yes

No

Does client give: Consent to receive SMS reminders on their mobile phone number? *

Yes

No

Does client give: Consent to receive emails? *

Yes

No

Please confirm that the young person consents to contacting parent/caregiver *

Yes

No

Caregiver Details

Name: *

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Address: *

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Postcode: *

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Landline number: *

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Mobile number: *

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Email address: *

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Has the referral been discussed with and agreed by the caregiver? *

Yes

No

*Please note, we require consent of the caregiver for anyone under 16 years of age to process the referral

How can we get in touch with the Parent/Caregiver?

Leave a message with someone answering their phone *

Yes

No

Leave a message on their answering machine *

Yes

No

Send reminders via text message to their mobile *

Yes

No

Send a message via email *

Yes

No

GP Details

Unfortunately if the clients GP is not listed in the drop down we are unable to offer them support via our service. Please search NHS choices for their local IAPT provider.

We are required to notify the clients GP that they are accessing our service. Please provide permission for us to write to the GP with this information.

GP Surgery *

Does the client give consent for their GP to be contacted? *

Yes

No

Details of Referrer

Name of Referrer *

Agency Name *

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Address

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Town/City *

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Post Code *

Telephone number

I confirm the person I am referring gives permission for you to discuss details of their referral with me *

Yes, client gives permission to discuss details

No, client does not gives permission to discuss details

Presenting Problem

Please provide a brief summary of clients problem. *

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To help us to continue delivering quality care, from time-to-time trainee practitioners are required to shadow our qualified practitioners during live appointments.

Do you consent for a trainee to shadow your initial appointment? Please note: should you provide consent now, you can change your mind at any point before or during your appointment. *

Yes

No

To help us to continue delivering quality care, for practitioner-training purposes, do you consent to your initial appointment being recorded if asked by your practitioner? *

Yes

No

Please note: should you provide consent now, you can change your mind at any point before or during your appointment.

Additional Information

Marital Status *

Sexual Orientation *

Ethnic Origin *

Religion *

Main Language *

Is an interpreter required?

Yes

No

Does client have any problems speaking, reading or writing English? *

Yes

No

If Yes please give details

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Does client have any Disability? *

Does client have any Long Term Conditions? *

Has client ever served in the British Armed Forces or are a dependent of someone serving? *

Is client or their partner expecting a child, or have a child under 24 months? *

Yes

No