Private (Self-Funding) Adult Self-Referral Form

FILL OUT THIS FORM IF YOU ARE 19 YEARS AND OVER, AND WISH TO BE SEEN FOR A PRIVATE ASSESSMENT

ALL fields need to be completed for your referral to be accepted

Title* !

Surname* !

First name* !

Date of Birth*(dd/mm/yyyy) !

What would you like to be called by staff at the Centre

NHS Number (UK residents only)

Address* ! !

Best phone number to contact you on during the day* !

Email* !

Preferred language* !

Is an interpreter required?* !

Yes

GP Name* !

GP Address* ! !

GP Telephone number

Emergency contact (the name and number of the person we would call in an emergency if you are at the Centre)* ! !

Additional Information

Do you see any other professionals for help with anything?* !

Yes

If yes, please write down the name of the professional who you see, where you go to see them, and what you see them for.

Do you have any health or mobility issues that we should be aware of?* !

Yes

If yes, please write down what these are

Do you currently take any medication?* !

Yes

If yes, please write down what you take and what it is for

Do you experience any of the following?

Low mood or depression* !

Now

In the past

Never

Not sure

Anxiety unrelated to stammering* !

Now

In the past

Never

Not sure

Reason for contacting the Michael Palin Centre

I understand that there is a fee to be seen privately at the Michael Palin Centre and that appointments are made only when payment is received.

A member of the Michael Palin Centre staff will contact you by phone or by email within the next 3 weeks to talk about your self-referral and to make an assessment appointment

Please write down any preferred days or times (during office hours) for staff to contact you