Self referral form | GM Resilience Hub: Critical Incident & Trauma Clinical Questionnaire

GM Resilience Hub: Critical Incident & Trauma Clinical Questionnaire

Looking after your emotional and mental health

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First Name *

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Last Name *

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Date of Birth *

Home Address Line 1

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Home Address Line 2

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Home Address Line 3

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Home Town/City

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Home Post Code *

Email Address *

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Mobile Phone Number *

Do you give consent for us to leave a message on this number? This consent will include if another person answers your phone. *

Yes

SMS Consent *

Yes

Home Phone Number

Do you give consent for us to leave a message on this number? This consent will include if another person answers your phone.

Yes

Gender *

Is your gender identity the same as the gender you were given at birth? *

Yes

Religion

Preferred Language

Ethnicity

Do you consider yourself to have a disability - a physical or mental impairment that has a substantial and long-term negative effect on your ability to do normal daily activities ?

Behavior and Emotional

Hearing

Learning Disability

Manual Dexterity

Mobility

Neurodiversity (such as ADHD or ASD)

None

Perception of Danger

Personal Care

Progressive Condition

Sight

Speech

Other (free text)

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Where did you hear about us? *

We will not get in touch with your GP without your consent, unless you are identified as requiring urgent help and we are unable to contact you directly to discuss this within a safe timeframe.

In these circumstances we may contact your GP, in confidence, in order to ensure alternative support is available to you..

Please select your GP Practice from the drop down list.

If your surgery is not on the list above please provide details.

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Employer

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I accept terms and conditions. *

Contact Telephone: 0333 009 5071

Contact Email: GM.help@nhs.net