LTC Professional Referral form

Please only complete this form if you are a long-term condition health professional making a referral to the Blackpool Healthier Minds team for a patient with a diagnosed long term physical health condition. Alternatively, you can download and complete this form.

If you are a professional but do not meet the above criteria to complete our LTC professional referral form, then please support your client to self-refer online [Self-referral form] or by phone on 01253 955700

    Patient Details:

    Referrer's Details:


    YesNo

    Next of Kin/Emergency Contact Details:

    Referral Information

    Long term physical condition:
    For each condition,please tick and give the date of diagnosis:

    COPD / Respiratory Disorder

    Diabetes

    MSK Problems

    Chronic Pain

    Cardiovascular Disease

    IBS

    ME

    Fibromyalgia

    Mental Health Problem:

    Anxiety

    Panic Attacks

    Depression

    Excessive worrying

    Unhelpful or distressing thoughts

    Other - please give details:

    Please confirm your details below if you give consent for your details to be shared.

    I give my consent for the information contained in this referral to be shared with the Blackpool Healthier Minds team.