Self-Referral form

    Are you over the age of 16?*
    YesNo
    Are you registered with a GP Practice in Blackpool or Cleveleys?*
    YesNo
    (If you are not registered with a GP in Blackpool or Cleveleys, you may still be able to access our courses. If you have a Fylde or Wyre GP you may be able to access Mindsmatter instead).

    Are you in a crisis and need urgent help?*
    YesNo

    Personal Details:

    Gender*:
    MaleFemalePrefer not to say

    Permission to leave voicemail?*:
    YesNo

    Permission to send text message reminders?*:
    YesNo

    What day(s) are you unavailable for us to contact you?:
    MondayTuesdayWednesdayThursdayFriday

    What time of day are you unavailable for us to contact you?:
    MorningAfternoon

    Permission to contact you by email?*:
    YesNo

    GP Details:


    Blackpool Healthier Minds provides a service for people with a Blackpool/Cleveleys GP. However, if you have a GP that is no on this list, you may still be eligible to access our courses.

    Additional information:

    Please select*:
    Respiratory disease including AsthmaCancerChronic Fatigue syndromeChronic painDementiaDiabetesEpilepsyFibromyalgiaHeart failureIrritable Bowel Syndrome (IBS)Medically unexplained conditionsOther

    Is this referral related to your long term condition?*:
    YesNo

    Are you an NHS employee?
    YesNo

    Please select the NHS organisation that you work for:

    Do you have any Mobility issues?*:
    YesNo

    Please state if you have recently been involved in a traumatic event*:
    YesNo

    Are you (or your partner) pregnant or do you have caring responsibility for a child under 24 months?*:*:
    YesNo

    Do you require and interpreter?*:
    YesNo

    Next of kin details:

    This service is only available to patients over the age of 16, registered with a Blackpool GP. If you are in the Fylde or Wyre area, please visit Minds Matter to make a referral.

    We are sorry...

    Your responses to our questions have indicated that Blackpool Healthier Minds may not be the most appropriate treatment for you or that further information is required to identify the most suitable option.

    If you are experiencing anxiety and depression then Blackpool Healthier Minds may still be suitable for you. Please contact us on 01253 955700 or email bfwh.healthierminds@nhs.net for further information. Or you may wish to register for a welcome call assessment online at:
    https://www.bfwh.nhs.uk/our-services/healthier-minds/self-referral/

    If you are receiving help from another mental health team, please contact them for more information rather than referring to us.

    If you are having thoughts about harming yourself or feel you are in crisis and need urgent help today please call 111 or:

    • Contact your GP and request an emergency appointment

    • Attend the Urgent Care Centre at Blackpool Victoria Hospital

    • SHOUT – free 24/7 text service for anyone in crisis anytime, anywhere. Text Shout to 85258

    • Phone the Mental Health Helpline on 0800 915 4640 (open Monday to Friday from 7pm until 11pm and from 12 midday to 12 midnight at weekends)

    If your main problem is alcohol or drug use, please contact Horizon https://www.horizonblackpool.uk/

    We are sorry...

    Your responses to our questions have indicated that Blackpool Healthier Minds is not the most appropriate service for you as we work with people age 16 plus. We would advise contacting your GP in the first instance to discuss alternatives.

    If you are receiving help from another mental health team, please contact them for more information rather than referring to us.

    If you are having thoughts about harming yourself or feel you are in crisis and need urgent help today please call 111 or:

    • Contact your GP and request an emergency appointment

    • Attend the Urgent Care Centre at Blackpool Victoria Hospital

    • SHOUT – free 24/7 text service for anyone in crisis anytime, anywhere. Text Shout to 85258

    • Phone the Mental Health Helpline on 0800 915 4640 (open Monday to Friday from 7pm until 11pm and from 12 midday to 12 midnight at weekends)

    • If your main problem is alcohol or drug use, please contact Horizon https://www.horizonblackpool.uk/