Self referral formThis form will take 5-10 minutes to complete. Name * First Name Last Name Gender Male Female Indeterminate Pronouns She/her He/him They/their/them Date of birth * MM DD YYYY Address Address 1 Address 2 City State/Province Zip/Postal Code Country Phone * (###) ### #### Email * Main reasons you are requesting support * tick all that apply Low moods/depression Anxiety Relationship struggles Anger Obsessions/compulsions Addiction (drugs, alcohol, gambling) Historic trauma Victim of a crime Physical health issues impacting mental health Grief I have issues with food I just want to talk to someone Please give us a brief overview of what you are seeking support with * Have you been to the GP regarding your mental health? * Yes No Have you ever been seen by NHS Mental health services * Yes No Is your mental health affecting your employment or education? * Yes No Emergency Contact Name * First Name Last Name Emergency Contact Relationship Parent Spouse/Partner Sibling Son/daughter Other Emergency Contact Phone * (###) ### #### Ethnicity White Mixed heritage Asian or Asian British Black or Black British Other ethnic groups Not known Work status * Employed Student Retired Not in employment, training or education GP Practice * British Armed Forces * Are you or a member of your family a former or serving member of the British Armed Forces. No I am a serving member I am a veteran Family member who is serving or former member Do you have an issues with accesibilty that we may need to take into account for your appointments Please tick here if you want to discuss our financial hardship fund to further subsidise your sessions Yes please Thank you for taking the time to complete this referral. You will be contacted via email with information to arrange a pre-therapy appointment. Please check your junk mail for an email from admin@incharleysmemory.com. We try to respond to all referrals within 48 hours.
