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Self referral
Name
Address Line 1
Address Line 2
Town or city
Postcode
Email address
Telephone number
Preferred method of contact (select as many methods as you prefer)
Phone Call
Text
Email
Languages spoken
Date of birth
Do you consent to text messages / voice mail?
Yes
No
GP name and contact details
Gender
Male
Female
Ethnicity
---
White English
White Irish
English / Welsh / Scottish / Northern Irish / British
Irish
Gypsy or Irish Traveller
Any other White background
Mixed / Multiple ethnic groups
White and Black Caribbean
White and Black African
White and Asian
Any other Mixed / Multiple ethnic background
Asian / Asian British - Indian
Asian / Asian British - Pakistani
Asian / Asian British - Bangladeshi
Asian / Asian British - Chinese
Any other Asian background
Black / African / Caribbean / Black British
African
Caribbean
Any other Black / African / Caribbean background
Other ethnic group
Arab
Any other ethnic group
Religion
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Islam
Christianity
Buddhism
Hinduism
Judaism
Sikhism
Confucianism
Jainism
Shinto
Taoism
Zoroastrianism
Atheist
Other
What is the reason for your referral? What troubles you?
Are there any significant risks we should be aware of such as suicidal thoughts you may be having?
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