Adult Self-referral

Fill out this form if you are 19 years or over and live in Camden or Islington, or have a Camden or Islington GP

 

 

    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:

    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.

    THE MICHAEL PALIN CENTER HELPLINE

    Sometimes you just need someone to talk to

    HELPLINE

    Sometimes you just need someone to talk to

    Our Helpline, 020 3316 8100, is open during office hours (9am-5pm) and voicemail messages can be left when the office is closed.

    “The MPC ACT course has had an immediate impact on my practice as an SLT working with young people with a stammer. All the practical activities meant that I was able to implement elements of this approach literally the next day with empowering results for my teenage clients. Its emphasis on acceptance makes it an important resource for all therapists and essential for those working with people who stammer.”

    ×

    I would like to become a friend of the Michael Palin Centre for Stammering and receive emails with news and information about the Centre and fundraising events.

    * indicates required
    I’m also happy for the Michael Palin Centre to call me occasionally about supporting the Centre’s work.
    Charitable donations to the Michael Palin Centre are administered by The Whittington Health Charity, Registered Charity Number 1056452 www.whittingtonhealthcharity.org. For this purpose alone, The Whittington Health Charity will also hold your details. We take your privacy seriously and will never sell or swap your details with other third parties. You can withdraw your consent to be contacted at any time by calling 020 3316 8100 or by emailing [email protected] Information about how the Trust protects personal data is set out in our privacy policy.
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