Self-referral form for Think Wellbeing Knowsley

To refer yourself for our talking therapies, please fill in the form below or, alternatively, call 0151 290 4999. Please note: this service is for people age 16 and over only. This web form is for client self-referrals only. If you are professional wishing to assist a client to self-refer, please call the service in the presence of the client, as consent will be needed to accept and process the referral. Thank you.

Required
Required
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Date of birth Required
Address Required
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Do you have Email? Required
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Address of your GP practice? Required
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Are you ex-British Armed Forces?
Do you consider yourself to have a disability? Required
Do you have a long term health condition?
Do you require wheelchair access? Required
Do you require an interpreter? Required
Please let us know any days and times you are definitely NOT available

Declaration

As part of providing you with direct care, the Trust may have to share your information with other partner organisations. To find out more information about this, please refer to our Privacy Policy.

By clicking submit, I agree to the Trust contacting me using the details given above. I understand that the Trust will:

  • securely store the information relating to my referral (and subsequent care, where applicable) in paper and/or electronic format
  • keep the records for as long as required in the Records Management Code of Practice for Health and Social Care 2016 (or for longer if it is appropriate)
  • confidentially destroy records when necessary
Required