Self-Referral form

    Are you over the age of 16?*
    YesNo
    Are you registered with a GP Practice in Blackpool?*
    YesNo
    Do you have a diagnosis of any of the following conditions; Schizophrenia, bipolar disorder, personality disorder?*
    YesNo
    Are you in a crisis and need urgent help?*
    YesNo
    Are you seeking support to help you manage uncontrollable anger?*
    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 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 Supporting 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 Supporting Minds may still be suitable for you. Please contact us on 01253 955700 or email bfwh.supporting.minds@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/supporting-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 Supporting 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/