Self-Referral form

Personal Details:

Title*:
—Please choose an option—MrMrsMissMsDrRevProf

First name*:

Last name*:

Date of Birth*:

Gender*:
MaleFemalePrefer not to say

Address line 1*:

Address line 2:

Town/City*:

County*:

Postcode*:

Phone number*:

Phone type*:
—Please choose an option—Home phoneMobile phoneWork phoneother phone

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

Email address*:

Permission to contact you by email?*:
YesNo

GP Details:

GP Name:

GP Practice Name*:
—Please choose an option—Abbey DaleAdelaide StreetArnold Medical CentreBloomfield Medical CentreCrescent SurgeryCleveleys Group PracticeElizabeth Street SurgeryGlenroyd Medical CentreGP Led Health CentreGrange Park Health CentreHarris Medical CentreHighfield SurgeryLayton Medical CentreMarton Medical PracticeNorth Shore SurgeryNewton Drive Health CentreSouth King Street Medical CentreStonyhill Medical PracticeSt Pauls Medical CentreVicarage Lane SurgeryWaterloo Medical Centre
Blackpool Healthier Minds provides a service for people with a Blackpool GP. If you have a Blackpool GP that is not on this list, please telephone us on 01253 955700.

GP phone number*:

Additional information:

Nationality*:
—Please choose an option—EnglishScottishWelshIrishBritishother

Ethnicity*:
—Please choose an option—White - BritishWhite - IrishWhite - Any other White backgroundMixed - White and Black CaribbeanMixed - White and Black AfricanMixed - White and AsianMixed - Any other mixed backgroundAsian or Asian British - IndianAsian or Asian British - PakistaniAsian or Asian British - BangladeshiAsian or Asian British - Any other Asian backgroundBlack or Black British - CaribbeanBlack or Black British - AfricanBlack or Black British - Any other Black backgroundOther Ethnic Groups - ChineseOther Ethnic Groups - Any other ethnic groupNot Stated - Not StatedNot known - Not known

Religion*:
—Please choose an option—No religious group or secularAtheist / AgnosticChurch of EnglandOther protestantOrthodox ChristianRoman CatholicOther ChristianMuslimShi'ite MuslimSunni MuslimSikhJewishOrthodox JewishBuddhistHinduJainZoroastrianRastafarianAny other religionNot stated

Sexual orientation*:
—Please choose an option—HeterosexualLesbian or gayBisexualOtherNot knownNot stated

Disability*:
—Please choose an option—No disabilityAutistic spectrumHearingLearning DisabilitySightSpeechOtherDo not wish to say

Do you have any long-term medical conditions?*:
—Please choose an option—YesNoDon't knowDo not wish to say

Are you an NHS employee?
YesNo

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

In relation to the British Armed Forces, are you*:
—Please choose an option—Dependant of a ex-services memberNot an ex-services member or their dependantDo not wish to sayNot known or Not SureEx-services member

Next of kin details:

Name*:

Contact number*:

Relationship to you*:
—Please choose an option—BrotherCarerChildCivil PartnerCousinDependantFatherFather in lawFoster ParentGrandmotherGrandfatherGuardianHusbandMotherMother in lawNephewNieceNext of KinNon-dependantNot KnownOtherPartnerRelativeSisterSpouseStep BrotherStep FatherStep MotherWife

Where did you hear about the service?*:
—Please choose an option—AdvertisementColleagueCollege/Further EducationCounty CouncilEmployerEmployment – Job CentreEmployment – Other servicesFriendFamily MemberGPWellbeing HelplineOther ServiceOther not specifiedSchoolSocial MediaSocial ServicesUniversity

Please leave this field empty.

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/