SELF REFERRAL FORM

If the service you wish to access is based in Stockport please post the referral form to:

Self Help Services

Stockport Psychological Wellbeing Service

Brookfield House

195-199 Wellington Road South

Stockport

SK2 6NG

If the service you wish to access is based in Manchester, Trafford, or Salford please post the referral form to:

Self Help Services

1st Floor East

Oakland House

76 Talbot Road

Old Trafford

Manchester

M16 0PQ

Service

What is the name of the Service you would like to access?

Your Details

Name: / Date of Birth:
Address: / Male or Female:
NHS Number:
Post Code: / Tel No: / Mobile:
Email Address:
We will try to contact you by telephone unless otherwise advised.
Please if possible include a mobile number in addition to a landline.
Please tick (a), (b), (c) if you donot give us permission
(a) to leave a message with someone answering my phone □
(b) to leave a message on my answering machine □
(c) to send reminders via text message to your mobile □

Your GP’s Details

GP Name: / Practice Tel No:
Practice Address: / Practice Fax No:
We are required to notify your GP that they are accessing the service. Please select yes below if you gives us
permission to write to their GP with this information. Please note that unless you give us permission to contact your GP
we will be unable to offer you this service.
Permission to contact GP: / Yes □ No □

About You

Please give brief details of why you wish to gain access to this service
Are you currently in receipt of any other form of therapy or seeing any other health care professional at present?
(e.g. psychologist/psychiatrist)
Yes / (please give details below) / No
Have you had any formal diagnosis from a GP, psychiatrist or other mental health professional?
Yes / (please give details below) / No
Are you currently taking any medication, which has been prescribed by a doctor?
Yes / (please give details below) / No
Have you had any thoughts of suicide within the past month, which you have wanted to act upon?
Yes / (please give details below) / No
Please give details of all the psychological/psychiatric conditions, which you feel you suffer from, or have been diagnosed as suffering with:
Where did you hear about the service?

Please outline any specific needs which we may have to take account of:

Language
Cultural
Access
Travel
Disability
Other
Details:

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