Private Adults Self-referral

Fill out the form if you are 19 years and over, and wish to be seen for a private assessment.

ALL fields need to be completed for your referral to be accepted.

    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):

    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.

    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.

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