Self Referral Step 1 of 4 25% Consent The information you provide via this online form will be accessed by the Jersey Talking Therapies (JTT) team to contact you and to administer your appointments. The information you share with us during our engagement will be held in secure systems and the JTT patient record, accessed only by those that need to know to provide care and treatment. We may share information with other health and care professionals who need to be involved in your care to ensure you receive the correct treatment at the right time. We will also share information with other professionals and authorities if we are concerned about your safety and welfare, the safety or others or if you have or are about to commit a serious crime. If we have to do this, we will, in most cases, let you know. The information you submit will be retained in line with our retention schedules. For more information about how Health and Community Services process your data and your data protection rights, please visit gov.je/HCSPrivacyBefore completing this form, please confirm the following:(Required) You are not in crisis or requiring urgent help You are ages 18 or over and registered with a GP in Jersey You are not currently waiting to access another mental health service Personal InformationTitleTitleMr.Mrs.Miss.Sir.Dr.First Name(Required)Surname(Required)Date of Birth(Required) Day Month Year Gender(Required)GenderMaleFemaleNon-BinaryOtherPrefer not to sayAddressAddress Line 1(Required)Address Line 2Parish(Required)Postcode(Required)Contact DetailsEmail(Required) Do we have consent to contact you by email? Yes No Mobile phoneDo we have consent to leave a message on your Mobile Number? Yes No Home PhoneDo we have consent to leave a message on your Landline? Yes No Would you like us to send you SMS Text Reminders for appointments? Yes No Further InformationHow would you describe your ethnic origin?White - JerseyWhite - PolishWhite - PortugueseIndianPakistaniBangladeshiChineseAny other Asian backgroundCaribbeanAfricanAny other Black, Black British, or Caribbean backgroundWhite and Black CaribbeanWhite and Black AfricanWhite and AsianAny other Mixed or multiple ethnic backgroundEnglish, Welsh, Scottish, Northern Irish or BritishIrishGypsy or Irish TravellerRomaAny other White backgroundArabAny other ethnic groupWhat is your preferred spoken language?AfrikannsAlbanianArabicArmenianBasqueBengaliBulgarianCatalanCambodianChinese (Mandarin)CroationCzechDanishDutchEnglishEstonianFijiFinnishFrenchGeorgianGermanGreekGujaratiHebrewHindiHungarianIcelandicIndonesianIrishItalianJapaneseJavaneseKoreanLatinLatvianLithuanianMacedonianMalayMalayalamMalteseMaoriMarathiMongolianNepaliNorwegianPersianPolishPortuguesePunjabiQuechuaRomanianRussianSamoanSerbianSlovakSlovenianSpanishSwahiliSwedishTamilTatarTeluguThaiTibetanTongaTurkishUkranianUrduUzbekVietnameseWelshXhosaDo you require an interpreter or help need help with communication? Yes No Additional information e.g. BSL InterpreterDo you consider yourself to have a disability? Yes No Please give details about your disabilityDo you have any of the following long term conditions? Asthma Diabetes Chronic Obstructive Pulmonary Disease (COPD) Heart Disease Musculoskeletal (MSK)/Chronic Pain Skin condition including Eczema Irritable Bowel Syndrome (IBS) Tinnitus Long COVID Fatigue Persistent Physical Symptoms/Medically Unexplained Symptoms Other Other condition(s)Do you have any children under the age of 18 living in your household? Yes No To make our service accessible to your needs, please let us know if you are: Family with child under one year Family with child under two years Family with children under one year Family with children under two years Are you or your partner pregnant? Yes No How can we help you?Please detail the problem you are seeking help for(Required)
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