Self-referral form for Think Wellbeing Wigan

To refer yourself for our talking therapies, please fill in the form below or, alternatively, call 01942 264051 (Leigh) or 01942 255675 (Wigan). Please note: this service is for people age 16 and over only. This web form is for client self-referrals only. If you are professional wishing to assist a client to self-refer, please call the service in the presence of the client, as consent will be needed to accept and process the referral. Thank you.

* Fields are required
First name * Surname *
Gender * Date of birth *
Address * Postcode *
Telephone number *  
Can we leave you messages on your voicemail / answer-machine?
Name of your GP practice *
Address of your GP practice *
Your nationality *
Your ethnicity *
Are you ex-British Armed Forces? *
Do you consider yourself to have a disability? *  
If yes, what type of disability do you have?
Do you have a long term health condition?
If yes, what health condition do you have?
What is your relationship status?
How would you describe your sexual orientatation?
What is your religion?
Do you require wheelchair access? *
Do you require an interpreter? *
If yes, which language do you require?
Please let us know any days and times you are definitely NOT available.  Monday 9am-1pm
Monday 1-5pm
Tuesday 9am-1pm
Tuesday 1-5pm
Wednesday 9am-1pm
Wednesday 1-5pm
Thursday 9am-1pm
Thursday 1-5pm
Friday 9am-1pm
Friday 1-5pm
How did you hear about our service?
Please tick this box to confirm you are registered with a GP in Ashton, Leigh or Wigan. *
Declaration
As part of providing you with direct care, the Trust may have to share your information with other partner organisations. To find out more information about this, please refer to our Privacy Policy.

By clicking submit, I agree to the Trust contacting me using the details given above. I understand that the Trust will:
  • securely store the information relating to my referral (and subsequent care, where applicable) in paper and/or electronic format
  • keep the records for as long as required in the Records Management Code of Practice for Health and Social Care 2016 (or for longer if it is appropriate)
  • confidentially destroy records when necessary

 

Thank you. Your self-referral to Think Wellbeing Wigan service has been received and you will be contacted as soon as possible.