Skip to main content
Roshni Ghar
Making equality in mental health care a reality
You are here
Home
Self-Referral Form
Your Details
First Name
*
Middle Name
Last Name
*
Date of Birth
*
Day
Day
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
Month
Month
Jan
Feb
Mar
Apr
May
Jun
Jul
Aug
Sep
Oct
Nov
Dec
Year
Year
1922
1923
1924
1925
1926
1927
1928
1929
1930
1931
1932
1933
1934
1935
1936
1937
1938
1939
1940
1941
1942
1943
1944
1945
1946
1947
1948
1949
1950
1951
1952
1953
1954
1955
1956
1957
1958
1959
1960
1961
1962
1963
1964
1965
1966
1967
1968
1969
1970
1971
1972
1973
1974
1975
1976
1977
1978
1979
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
NHS Number
Email
*
Street Address
*
Street Address Line 2
City
Postcode
*
Phone Number
*
Alternative Phone Number
Preferred Communication Method(s)
Phone
Email
Postal Mail
SMS
Privacy Preferences
Are there any communication methods that you would prefer us NOT to use:
Do not email
Do not phone
Do not mail
Do not sms
Medical Details
GP Practice / Medical Centre
*
Please provide a brief description of your problem, including details of any previous or current mental health problems
*
Diagnosis
*
Agoraphobia
Anxiety
Asthma
Bipolar
Blood pressure
Cholesterol
Depression
Diabetes
Eating disorder
Hearing voices
Isolated
Loneliness
Long term health condition
Low mood
Obsessive Compulsive Disorder
Panic attacks
Psychosis
Schizophrenia
Self harm
Stress
Do you have any Long Term Physical Health Condition?
Asthma
Cancer
Chronic Kidney Disease
Chronic Obstructive Pulmonary Disease
Coronary Heart Disease
Dementia
Non Insulin Dependent Diabetes Mellitus
Insulin Dependent Diabetes Mellitus
Epilepsy
Heart Failure
Hypertension
Multiple Sclerosis
Parkinson's Disease
Severe Mental Health Problems
Stroke and Transient Ischaemic Attack
Musculoskeletal Disorder
Other
Prefer not to say
Do you have any additional needs?
Require help from a support worker
Wheelchair user
BSL / Hearing
Sight
Are you currently pregnant?
Yes
No
Have you been prescribed any medication for the condition you are seeking support for?
Yes
No
Have you accessed any counselling before?
*
Yes
No
If so, when and where?
*
Have you or a family member been a victim of crime?
Yes
No
If so, please give more details
Do you have any money worries?
Yes
No
If so, please give details
Demographic Information
Employment Status
- Select -
Employed
Self Employed
Not Working
Retired
Student
Carer
Do you require an interpreter or help with Communication?
*
Yes
No
What is your first language?
*
Ethnicity
- Select -
Pakistani
Bangladeshi
Arab
Indian
White/British
Afro/Caribbean
Other
Do you follow a Religion?
- Select -
Muslim
Christian
Jewish
Buddhist
Sikh
Atheist
Humanist
Jain
Other
Gender
- Select -
Female
Male
Transgender
Other
Sexuality
- Select -
Gay
Lesbian
Bisexual
Heterosexual
Other
Not disclosed
Not asked
Dependants / Carers
Are you a carer?
Yes
No
What are your living arrangements?
- Select -
Living with parents/extended family
Living with immediate family only (e.g. spouse and children)
Living alone
How did you hear about us?
We are open Monday to Friday, 9:15am to 4:30pm - what times are you generally available during the week?
Consent
*
Children and young people aged 16 years and under will require consent from their parent, or someone with parental responsibility for them.
I am aged 16 or under
I am over 16
Contact Details for Parent/Guardian
*
