You have completed 0% of this survey 0% default Caution: JavaScript execution is disabled in your browser or for this website. You may not be able to answer all questions in this survey. Please, verify your browser parameters. About you (This question is mandatory) First name (This question is mandatory) Last name (This question is mandatory) Date of birth We only accept referrals for children and young people under 18. If you are under 13 then we will need parental /guardian consent to process this form. If you are under 13 and have concerns about us contacting your parent or guardian then please tell us why later in this form Answer must be between 15/09/2006 and 15/09/2024 Date format: dd/mm/yyyy Open date/time selector Format: dd/mm/yyyy 2006-09-15 2024-09-15 DD/MM/YYYY (This question is mandatory) Home address If you live outside Leicester, Leicestershire and Rutland but are registered at a practice within this area then please see your GP to request a referral. (This question is mandatory) Postcode Enter a postcode in Leicester, Leicestershire and Rutland (This question is mandatory) I give consent for you to send mail to this address If you do not consent for us to contact you either at your home address, your mobile phone or your email then we will need to contact your GP about your referral. Yes No (This question is mandatory) Telephone number This is the number we will call you on to discuss your referral (This question is mandatory) I give consent for you to leave a voicemail message and to contact me using a secure service If you do not consent for us to contact you either at your home address, your mobile phone or your email then we will need to contact your GP about your referral. Yes No (This question is mandatory) Email address it would help us to have an email contact so we or an onward referrer can email you about your referral rather than write. Please check the format of your answer. (This question is mandatory) I give consent for you to contact me on this email address This is the email we may contact you on using a secure service. If you do not consent for us to contact you either at your home address, your mobile phone or your email then we will need to contact your GP about your referral. Yes No NHS Number Find this on a repeat prescription, NHS letters about you, from your GP or you can search for this via https://www.nhs.uk/nhs-services/online-services/find-nhs-number/ GP practice (This question is mandatory) Sex assigned at birth This is the gender you were assigned at birth Gender identity This is your preferred gender. Preferred pronoun Examples include he, she, they. This helps us address you correctly when we write to you Ethnicity Choose one of the following answers None Asian or Asian British - Bangladeshi Asian or Asian British - Chinese Asian or Asian Brish - Indian Asian or Asian Brisith - Pakistani Asian or Asian British - Any other Asian Background Black or Black British - African Black or Black British - Caribbean Black or Black British - Any other Black, African or Caribbean Mixed - White and Asian Mixed - White and Black African Mixed - White and Black Caribbean Mixed - Any other mixed or multiple ethnic background White - British White - Gypsy or Irish Traveller White - Irish White - Any other white background Other ethnic group - Arab Other ethnic group - any other ethnic group Religion Choose one of the following answers No religion Buddhist Christian Hindu Jewish Muslim Sikh Any other religion Are you a child in care? A child in care has been in the care of their local authority for more than 24 hours is also known as a looked after child. Yes No Are you aware of potential barriers to services? This might include caring commitments, support needed with transport to appointments, have limited access to the internet or a computer, require communication in a specific format, need an interpreter. Yes No Next Please confirm you want to clear your response? Exit and clear survey ×
