Self referral form | Referral Form

This study looks at how an intervention shown to reduce stress and enhance mood can be tailored for young professional footballers.

If you would like to take part, please complete the following questions about yourself and your wellbeing. If you have any questions about the study or completing this form, please contact the Performance Habits study team at performance-habits-project@york.ac.uk.

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First Name *

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Last Name *

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Date of Birth *

Address Line 1 *

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Address Line 2

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Town/City *

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Post Code *

Mobile Phone Number

Consent to receive Text messages to your mobile number?

Yes

Consent to receive Calls to your mobile number?

Yes

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

Yes

Email Address

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Email Consent

Yes

Ethnicity

GP Surgery *

If other, please specify

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I would like to receive a confirmation of the referral to the email address I specified above. Please check the spam folders within your email if you do not receive a confirmation in your inbox.

I can confirm I have read the Performance Habits Participant Information Sheet *