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Meridian Wellbeing IAPT Self Referral Form

Improving Access to Psychological Therapies Service is an NHS service providing easy access to psychological therapies for people experiencing depression & anxiety.

As a provider to the NHS, we are required to share information with your GP about your referral and treatment, which we may do either verbally or in writing.

If you are worried about acting on suicidal thoughts OR if you are worried about hearing voices or other psychotic symptoms - Contact your GP or specialist mental health services via The Crisis Resolution and Home Treatment Team on 0800 151 0023.

 Click the button below to start.

Start

Question 1 of 21

Full Name

Question 2 of 21

Address (including postcode)

Question 3 of 21

Date of Birth

Question 4 of 21

Gender

A

Female

B

Male

C

Other

D

Prefer not to say

Question 5 of 21

NHS number (if known)

Question 6 of 21

Phone Number(s)

Question 7 of 21

Email Address

Question 8 of 21

How would you prefer for us to contact you?

By completing this form you are giving your consent for us to contact you. 

A

Phone (including voicemail)

B

Text

C

Email

D

Post

Question 9 of 21

Nationality

Question 10 of 21

Ethnicity

Question 11 of 21

Are you able to read and write in English?

A

Yes

B

No

Question 12 of 21

Do you require an interpreter?

A

Yes

B

No

Question 13 of 21

How would you define your sexuality?

A

Homosexual

B

Heterosexual

C

Bisexual

D

Other

E

Prefer not to say

Question 14 of 21

Do you have any long term health conditions?

Question 15 of 21

Do you have mobility difficulties?

Question 16 of 21

Please tell us about your difficulties and what you would like help with.

Question 17 of 21

Your GP's Name(s)

Question 18 of 21

Your GP's Contact Information (including Practice address)

Question 19 of 21

Is there anything else you would like to share with us?

Question 20 of 21

How did you hear about our services?

A

GP

B

Other healthcare professional

C

Adult Social Care

D

Social Worker

E

Link Worker

F

Friend or family member

G

Internet

Question 21 of 21

By referring yourself to this service you are agreeing that the service may contact and share relevant information with your GP to facilitate your care

 

We will never release your information to third parties for marketing.

 

Do you give your consent?

 

A

I consent

Confirm and Submit