Adult Self-Referral Form for General Therapies Services
If you would prefer this form in another language or in large print, or you would like to make your referral over the phone, please speak with one of our specialist administrators on 01904 412551
Your Details
Full Name*
Name you preferred to be called (if different from full name)
Date Of Birth*
Home Address*
Home Postcode*
Email Address*
Mobile Number*
Do you have a preferred day or time for appointments?
Gender you identify with
Preferred pronouns
What ethnicity best describes you?*
Please choose
Any other Asian background
Any other Black background
Any other ethnic group
Any other mixed background
Any other White background
Asian or Asian British - Bangladeshi
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Black or Black British - African
Black or Black British - Caribbean
Mixed - White and Asian
Mixed - White and Black African
Mixed - White and Black Caribbean
Not stated
Other Ethnic Groups - Chinese
White - British
White - Irish
Equality Diversity and Inclusion Information
Is there any information you would like us to be aware of to help us meet your needs such as cultural or religious practices?
Please let us know if we need to be aware of any adjustments that might be needed such as an interpreter, wheelchair access etc.
Your GP's Details
Practice Name*
GP's Name*
Practice Address*
Practice Postcode*
Practice Telephone Number*
About Your Referral
What are your reasons for seeking support?*
Please give details including names & contact details of professionals / Care Co-ordinator involved.*
Please provide some details, including an indication of how it helped you.*
Please provide further information in the box below.*
We are asking the following two questions to make sure that we can care for you safely. If we are concerned that you or somebody else is at risk of harm and our therapy services are not best placed to support you we may need to suggest alternative support to you and we may need to share information with other healthcare professionals in an attempt to keep you or somebody else safe.
Please provide further information in the box below.*
Please provide further information in the box below.*
How You Heard About Us*
Data Protection
For the purposes of the General Data Protection Regulations 2016 (GDPR) / Data Protection, The Retreat Clinics is the data controller for the collection, processing, sharing and storage of this data. All information collected in this form will be for the sole purpose of providing a clinical service to you and will only be passed to third parties who support us in the administration of this service or where we have your consent to do this.
However, we may have to break this confidentiality where we have a legal obligation to comply with the law, for example if the information is required to detect a crime or apprehend an offender or to support a safeguarding issue such as where we are concerned that you or someone else is at risk of harm. We will share information in an attempt to keep you or someone else safe, this might mean us contacting other health professionals, a crisis service, or the police.
Further information about this can be found in our Privacy Notice on our website. View our privacy policy.
Our Privacy Notice will advise you of whom we share information with, how long we keep your information for and what your legal rights are in respect of your data. Alternatively, you can contact our Data Protection Officer for further information at: The Retreat Clinics, Tuke Centre, 28 Green Dykes Lane YO10 3HH or email us at: DPO@TheRetreatYork.org.uk.
All information is retained in accordance with our corporate retention guidelines.
Declaration
By submitting this form to The Retreat Clinics, you agree that the information you have provided is complete and true. You agree that:
You are aged 18 years or older.
You understand our terms of service, including our Data Protection statement, our cancellation policy, payment policy and refund policy. All of which are a condition of your service and agreement with us and can be found on our website https://theretreatclinics.org.uk/
All information about you will be shared with our therapists to allow them to provide a service to you.
You can withdraw from the service/agreement at any time; however, charges will still apply to all booked sessions as per our cancellation policy.
All information in this form will be treated as strictly confidential.
Submit
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Help in A Crisis
There are many things that can make us feel low or hopeless and these feelings can come and go but it is important to take them seriously.
If you are having thoughts of suicide, are harming yourself or have thoughts about self-harm it is important to tell someone.
These thoughts and feelings can be complex, frightening, and confusing but you do not have to struggle alone.
Whilst The Retreat Clinics is not able to provide crisis services, if you feel unable to cope or keep yourself safe, please contact your GP immediately, or contact an organisation who specialises in crisis support. We have listed some organisations below who may be able to help you.
Mental Health Innovations - support by text message
Mental health support by text message
