Self Referral Form

Please note: This service is unlikely to be suitable for you if you are at immediate or imminent risk to yourself or others. Please click here if you require immediate crisis help.

If you want to find out more about how we use your information please see this page to see our terms and conditions: Privacy Policy.

Designs in Mind is contracted by NHS Shropshire, Telford and Wrekin. To access our service you need to be registered with a Shropshire, Telford and Wrekin GP. If your GP is located in a different area, you can click here to find the contact details of the mental health services linked to your GP surgery.

If, for any reason, this referral form is being filled out by a third party, please note that the person must have consented to the referral being made and that information included on the form may be shared with the person.

New Referral Form

Enter your personal details

Please fill out your personal details so we can process your referral.

Title

First Name

Last Name

Phone/Mobile

Address Line 1

Address Line 2

Town/City

Post Code

Date of birth

Gender Identity

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

GP Surgery

Marital Status

How would you describe your ethnic origin?

If other please state

Religion

Health & Disabilities

Please give us information about your health and disabilities.

Do you have any disabilities we should be aware of?

Please give further details of disabilities

Do you have any long term health conditions?

Please give further details about long term health conditions

Please a brief description of the mental health difficulties you are experiencing?

Next of Kin

Please give us details about your next of kin.

Full Name

Relationship to yourself

Address Line 1

Address Line 2

City/Town

Post Code

Next of kin email address

Phone for next of kin

Terms & Consent

For us to process your referral, please read and agree to our terms.

How did you hear about our service?