Private Adults Self-referral

Name (required)

Date of birth (required)

Title (required)
MrMrsMsMissDrOther

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

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

Ethnicity (required): 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. (required)

Home address (required)

Post code (required)

Country (required)

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

Email (required)

Preferred language (required)

Interpreter needed (required)
YesNo

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

G.P.'s telephone number (required)

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? (required)
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? (required)
YesNo

If yes, please write down what these are.

Do you currently take any medication? (required)
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:

I understand that there is a fee to be seen privately at the Michael Palin Centre at that appointments are made only when payment is received. (required)

A member of the Michael Palin Centre staff will contact you by phone or by email about your self-referral and how to pay for a private assessment.

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

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