Self referral form | Referral Form

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This is due to software upgrade. Please ensure that you are not starting (or are unable to complete) a self referral before the time stated.

Referral Form

Thank you for your interest in the Performance Habits Programme.

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

* Indicates a required field

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
(please note that the 5-REPS programme requires contact via the phone) *

Consent to receive Text messages to your mobile number? *

Yes

Consent to receive Calls to your mobile number? *

Yes

Email Address *

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Email Consent *

Yes

Organisation e.g NWAS, TEWV *

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Department/Service (as relevant)

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Job Role (as relevant)

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Ethnicity *

GP Surgery (if you do not know your GP Surgery, please enter 'Unknown') *

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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 Programme details via the Performance Habits Programme website (https://performancehabits.org/) *

Contact Email: performance-habits-project@york.ac.uk