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Self-referral form for Think Wellbeing St Helens

To refer yourself for our talking therapies, please fill in the form below or, alternatively, call 01744 647 100. 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
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Date of birth Required
Address Required
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Do you have email? Required
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Can we leave you messages on your voicemail/answer-machine?
Permission to send text message reminders?
Permission to contact by email
Required
Address of your GP practice Required
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Please state if you have recently been involved in a traumatic event? Required
Are you currently expecting a child, or have you had a pregnancy or become a parent in the past 2 years? Required
Are you ex-British Armed Forces? Required
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?
Please let us know any days and times you are definitely NOT available
Required

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