Adult Self-referral

Please fill out as much information as possible. Fields marked * are required

Name (required)

Date of birth (required)

Title MrMrsMsMissDrOther

If "other", please enter your preferred title here:

What would you like to be called by staff at the Centre?

Ethnicity: White BritishWhite IrishAny other white backgroundWhite & black CaribbeanWhite & black AfricanWhite & AsianAny 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 backgroundOther Ethnic Groups - ChineseOther Ethnic Groups - any other ethnic groupI would prefer not to say

NHS no. (if known)

Home address (required)

Post code (required)

Best phone number to contact you on during the day (required)

Email (required)

Preferred language

Interpreter needed
YesNo

G.P.'s name and address [including postcode] (required)

G.P.'s telephone number

Emergency contact [the name and number of the person we would call in an emergency if you are at the Centre] (required)

Do you see any other professionals for help with anything?
YesNo

If yes, please write down the name of the professional who you see, where you go to see them, and what you see them for.

Do you have any health or mobility issues that we should be aware of?
YesNo

If yes, please write down what these are.

Do you currently take any medication?
YesNo

If yes, please write down what you take and what it is for.

Do you experience any of the following? (tick any that apply)
Low mood or depression: NowIn the pastNeverNot sure
Anxiety unrelated to stammering: NowIn the pastNeverNot sure

Reason for contacting the MPC:

A member of the Michael Palin Centre will contact you by phone or by email within the next 3 weeks to talk about your self-referral and to make an assessment appointment.

Please write down any preferred days or times (during office hours) for staff to contact you.

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