Self-Referral form Are you registered with a GP Practice in Blackpool?* YesNo Personal Details: Title*: ---MrMrsMissMsDrRevProf First name*: Last name*: Date of Birth*: Gender*: MaleFemaleNot specifiedUnknown Address line 1*: Address line 2: Town/City*: County*: Postcode*: Phone number*: Phone type*: ---Home phoneMobile phoneWork phoneother phone 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. Email address*: Permission to contact you by email?*: YesNo GP Details: GP Name: GP Practice Name*: ---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 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. GP phone number*: Additional information: Nationality*: ---EnglishScottishWelshIrishBritishother Ethnicity*: ---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*: ---No religious group or secularAtheist / AgnosticChurch of EnglandOther protestantOrthodox ChristianRoman CatholicOther ChristianMuslimShi'ite MuslimSunni MuslimSikhJewishOrthodox JewishBuddhistHinduJainZoroastrianRastafarianAny other religionNot stated Sexual orientation*: ---HeterosexualLesbian or gayBisexualOtherNot knownNot stated Disability*: ---No disabilityAutistic spectrumHearingLearning DisabilitySightSpeechOtherDo not wish to say Do you have any long-term medical conditions?*: ---YesNoDon't knowDo not wish to say 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 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 In relation to the British Armed Forces, are you*: ---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*: ---BrotherCarerChildCivil PartnerCousinDependantFatherFather in lawFoster ParentGrandmotherGrandfatherGuardianHusbandMotherMother in lawNephewNieceNext of KinNon-dependantNot KnownOtherPartnerRelativeSisterSpouseStep BrotherStep FatherStep MotherWife Where did you hear about the service?*: ---AdvertisementColleagueCollege/Further EducationCounty CouncilEmployerEmployment ServicesFriendFamily MemberGPWellbeing HelplineOther ServiceOther not specifiedSchoolSocial MediaSocial ServicesUniversity Please leave this field empty. 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.