Self referral form | Infected Blood Psychological Service Referral Form

Please note that the Infected Blood Psychological Support Service does not offer support for mental health emergencies or crises. More information on urgent support can be found on our website. https://infectedbloodpsychologicalservice.nhs.uk/urgent-care/

* Indicates a required field

Please select one of the options about the person filling in this form.

a. I am the person who needs support from the Infected Blood Psychological Service / I am a relative/friend helping the person to fill in the form

b. I am a healthcare professional / member of staff from another organisation referring a person who needs support

Before filling in this form, please read the information about why and how we may share your data.

https://infectedbloodpsychologicalservice.nhs.uk/consent-and-confidentiality/

Please tick the box at the bottom of the form

About you (the person who needs support) or the person you are referring to the service

Title (please selection an option)

First Name*

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Middle Name

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Last Name*

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What do you prefer to be called?

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Gender Identity*

Date of Birth*

Contact Details

Address Line 1*

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Address Line 2

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Address Line 3

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Town/City*

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Post Code*

Mobile Number

Can a message be left on your answer phone?*

Yes

Do you consent to being contacted by text message?*

Yes

Comments

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Home Telephone Number

Can a message be left on your answer phone?

Yes

Email Address:

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Comments

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Do you consent to being contacted by email?

Yes

How would you prefer to be contacted about this request? (please selection an option)

Support you need from us

Is there something you would like to write about what you are hoping the service can provide?

Characters remaining :

Select the Provider you would like to receive support from (please selection an option)*

If you are a healthcare professional/member of staff from another organisation referring someone to the service, please fill in this section:

I can confirm that I have obtained consent to refer this person to the service

Yes

Title:

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Name:

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Your job role (if applicable)

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Your organisation (if applicable)

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I agree for my data to be recorded, used in providing me with support and shared with other people or organisations as set out in the consent and confidentiality statement (tick box). *

Incomplete information

Terms and conditions

Please tick the checkbox to accept the terms and conditions.

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An error occurred with data entry

There was a problem sending these details.

Please check for invalid characters such as quotes (’ ‘ ´ `) and long dashes (– —) in any text you may have typed or pasted in, and try again.

If the problem persits, then please contact your service.

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