Self-Referral form

    Are you registered with a GP Practice in Blackpool?*
    YesNo

    Personal Details:

    Gender*:
    MaleFemaleNot specifiedUnknown

    Permission to leave voicemail?*:
    YesNo

    Permission to send text message reminders?*:
    YesNo

    What day(s) would you prefer to be contacted?*:
    MondayTuesdayWednesdayThursdayFriday

    What time of day would you prefer to be contacted?*:
    MorningAfternoonEvening

    Please note that we will do our best to match the time of day selected, however, not all teams have the capacity to offer evening appointments.

    Permission to contact you by email?*:
    YesNo

    GP Details:


    Supporting 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. If you have a Fylde or Wyre GP you may be able to access Mindsmatter instead.

    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 currently expecting a child, or have you had a pregnancy or become a parent in the last 12 months?*:
    YesNo

    Next of kin details:

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