Referral form | Resilience Hub Referral Form

Resilience Hub Referral Form

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Are you completing this referral on behalf of someone else? Please share your name and a contact phone and email address if so.

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Title

First Name*

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Middle Name

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Last Name*

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NHS Number

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*

Mobile Phone Number*

Consent to receive Text messages to your mobile number? *

Yes

If you have consented to being contacted via SMS, you will be opted into Choose and Book. This is a secure electronic service which allows you to choose an initial appointment convenient for you.

You will receive the link to Choose and Book via an SMS text message within 2 working days of submitting your referral to the Resilience Hub.

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

Home Phone Number

Consent to receive Calls to your home number?*

Yes

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

Yes

Email Address*

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Do you consent to receive emails from 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.

GP Surgery*

Surgery Name - Other

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Gender*

Is your gender the same as your gender assigned at birth?*

How would you describe your Ethnic origin?*

National Insurance number*

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Do you consent to your anonymous information being used for other purposes e.g. research in the NHS? Your personal details will be removed e.g. Name, DoB, Address, Postcode.*

Yes

Reason for referral*

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How did you hear about us?*

Are you being seen by another service currently? Please state name of Service?

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I would like to receive a confirmation of my self 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 accept terms and conditions. *