This form will take approximately 5 minutes to complete. The purpose is to gather your details as part of the self-referral process, so that we can register you with the correct information on our system and make sure that we support you appropriately.
Information on how we hold this data can be found at the following link: https://www.kmpt.nhs.uk/about-us/confidentiality-and-gdpr/personal-data-and-what-we-hold-about-you/
Please note you must be over 18 and registered with a GP in Kent and Medway to access this service.
Please complete this form with as much detail as possible. Once submitted, we aim to contact you by telephone within 72 hours (excluding weekends and bank holidays).
This form has been created following the patient identification and characteristics form to promote safe services and inclusivity for all, as per the Equality Act (2010).
Please note: This is a self-referral form only and must not be completed by anybody other than yourself.
There are 21 questions in this survey.
