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Talkzone
Self Referral

 

Please complete the referral form below.

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Data Sharing Statement​

Some of the data we collect from you at your Talkzone referral will be shared with the NHS as part of our funding agreement. This data includes your date of birth, postcode, gender and GP surgery but does NOT include your name or the reason you have made the referral.

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To find out more information about how your data is used, or to opt-out from additional data tracking and research, please visit the website https://www.nhs.uk/your-nhs-data-matters/

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How would you like to be known (pronouns)?
She/her
She/they
They/them
He/they
He/him
Other
Please describe your sexual orientation
Please describe your gender identity
Is your gender identity the same as it was assigned at birth?
Your date of birth
How is best to describe your ethnicity/ethnic origin?
White/British
White/Irish
White/Eastern European
White/Other
White & Black/British
White & Black/Caribbean
White & Black/African
White & Asian
Other mixed background
Black/British
Black/African
Black/Caribbean
Black/Other
Asian/British
Asian/Indian
Asian/Bangladeshi
Asian/Pakistani
Asian/Other
Chinese
Chinese/Other
Other ethnicity/ethnic origin
Are you part of any religious group?
Christian
Catholic
Buddhist
Hindu
Jewish
Muslim
Sikh
No religion
Other
How do you wish to be contacted via your home number?
How do you wish to be contacted on your mobile number?
Do you consent to be contacted on this email?
Yes
No
Not applicable
Do you consent to being contact by letter?
Yes
No
Not applicable
Do you have any mobility issues?
Yes
No
Maybe
Do you have any communication issues?
Yes
No
Maybe
Where would you prefer an initial assessment to take place?
Worksop
Retford
Either
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