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For self-referrals, please be aware we will attempt to contact you within 2 working days of receiving your form. If we are unable to make contact then we will close down this referral. You can refer back into us via the website or 0300 333 0000
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First Name
Last Name
Nickname
Gender
Select your option...
Male
Female
-
Agender
Androgyne
Androgynous
Bigender
Cis
Cis Man
Cis Woman
Gender Fluid
Gender Nonconforming
Gender Questioning
Gender Variant
Genderqueer
Intersex
Neutrois
Non-binary
Pangender
Transgender
Transgender (Man)
Transgender (Woman)
Ethnicity
Select your option...
Asian British
Asian Other
Bangladeshi
Black African
Black British
Black Caribbean
Black Other
Chinese
Indian
Mixed Other/Multiple Ethnic Background
Not Stated
Pakistani
Polish
Portuguese
White Welsh
White British
White Irish
White Other
DOB
NHS Number
Address
Postcode
Area
Select your option...
Rhondda
Cynon
Taff
Merthyr Tydfil
Bridgend
Out of Area
Who do you live with
What is the preferred method of contact? (Select one box only)
Letter
Telephone
SMS
Email
Which of the following methods are also suitable (Tick all that apply)?
Letter
Telephone
SMS
Email
Where would you prefer appointments?
Office
Home
Community
Where is the service user happy to have appointments? - Please tick all that apply
Telephone
Mobile
Email
Do you currently have any Domestic Abuse concerns or issues?
Yes
No
Domestic Abuse concerns or issues - Details
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