Refer Yourself

We accept self-referrals from clients who are aged 18 years and over and registered with a GP in Hull CCG.

EXCLUSION CRITERIA
……

Please note that Healthshare Hull are unable to treat patients who….
…have a GP outside of Hull CCG
…are under 13 years old 
…are under the care of a consultant for the same problem
…are presenting with difficulties that are due to having had a stroke
…are presenting with difficulties which are due to a learning disability
…need to be seen for equipment provision only (we only accept referrals for basic walking aids & crutches)

Paper referrals are required for patients who...
…are under 18 years old
…are unable to speak English or only speak limited English
…are hard of hearing or hearing impaired
…have mental health problems that prevent them from communicating via the telephone.

Please note that a telephone assessment is provided initially with the patient.

HELP WITH TRAVEL COSTS……
If you are referred to hospital or other NHS premises for NHS specialist treatment or diagnostic tests by your doctor, dentist or other health professional, you may be able to claim a refund of reasonable travel costs under the Healthcare Travel Costs Scheme (HTCS).  
Visit the NHS UK website to find out who is eligible for the scheme and how to make a claim.
HCT(T) Refund claim form - travel costs to receive NHS treatment.

By filling out this form and submitting it you consent to data being transferred via secure email.
We would be grateful if you could have your NHS number ready when contacting us or using this self-refer page.

 Please ensure you fill out all mandatory fields marked with an asterisk(*).
When you click the Submit button at the end of the form and it does not appear to work please check that you have completed the required fields.  When submitted successfully you should receive a completion message.

DEMOGRAPHIC INFORMATION
Please confirm if you are the patient or if you are completing this form on behalf of someone else*

Please select an option

Please state in what capacity you know the patient
Please state in what capacity you know the patient

First name*
Please enter your first name

Surname*
Please enter your surname

Date of birth*
Please enter your date of birth

**Please use the format DD/MM/YYYY**

What is your gender?

Please select an option

Address 1*
Please enter your address

Address 2
Please enter your address

County
Please enter your county

Post code*
Please enter your post code

Email Address
Please enter a valid email address

If you have provided an email address confirmation of your self-referral will be sent to you when you have successfully submitted the form.
Please check the spam folders within your email if you do not receive a confirmation in your inbox.

Please tick your contact devices*

Please select an option

We may need to contact you to discuss your referral or to arrange an appointment within the service. Please tick your preferred method of contact.*

Please tick one of the options

Landline number*
Please enter your landline number

Can voicemail messages be left on your landline?*

Please select an option

Mobile number*
Please enter your mobile number

Can voicemail messages be left on your mobile?*

Please select an option


GP name*
Please enter a GP name

GP surgery*
Please enter the name of your GP surgery

GP surgery telephone number (if known)
GP surgery telephone number (if known)

Is your GP aware of your self-referral?

Please select an option

NHS Number
Please enter your NHS number

What is your weight? Would you like to use lbs or kg?*

Please select either lbs or kg

What is your height? *
Please select your height from the dropdown menu

What is your current weight in kilograms?*
Please adjust the slider to your weight in kilograms

What is your current weight in pounds?
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What is your ethnicity?*

Please select an option

What ethnicity are you?
Please type your ethnicity in the box

Please enter ethnicity


CURRENT DIFFICULTIES
On what part of your body do you have a problem?*
Please enter what part of your body is affected

How long have you had this complaint?*
Please tell us how long you've had this complaint

Please give a brief description of why you need physiotherapy*
Please briefly explain why you need physiotherapy

Is the problem...*

Please select an option

Are you having difficulties sleeping?*

Please select an option

Have you had any other symptoms such as numbness, tingling, or muscle weakness?*

Please select an option

Please give details*
Please give details

Please give details of your symptoms

Are you able to carry out your normal activities?*

Please select an option

Have you suddenly lost any weight without trying?*

Please select an option

Please give details of your weight loss*
Please give details

Are the symptoms worsening?*

Please select an option

For back pain referral, do you currently have leg pain?

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Have you had any difficulties passing or controlling urine?*

Please select an option

Are you off work with this problem?*

Please select an option


We will inform your GP of your self-referral. Please tick 'No' if you do NOT wish your GP to be informed.*

Please select an option


Have you received, or are you currently receiving, treatment for this problem?*

Please select an option

Please give details*
Please give details

Are you currently taking any medication? *

Please select an option

Please give details*
Please give details


Do you suffer with depression or anxiety? *

Please select an option

Are your family and friends concerned about you?*

Please select an option

Please give details*
Please give details

Do you have any difficulties with thinking or understanding?*

Please select an option

Do you have any difficulties with hearing? *

Please select an option

If so, do you require access to a hearing loop?*

Please select an option

Do you feel this is related to your current problem? *

Please select an option

Do you have any problems with reading or writing? *

Please select an option

Do you have any difficulties with learning? *

Please select an option


Will you require an interpreter?*

Please select an option

What language would you need an interpreter for?*
Please select an option

Please provide us with any other information that you feel is relevant in the box below
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Do you require a chaperone for your face to face appointment? *

Please select an option

If you require a face to face appointment where would you rather be seen and at what time?
In order for us to plan your care please tick all days and times that are more convenient for you to attend an appointment. The service is open from 8am-8pm Monday to Friday.

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Where would you prefer to be seen?*
Please select a clinic

For clinic location details please go to Where We Do It

Please let us know what you are hoping to gain from our service*
Please give details

Where did you hear about our service?*

Please select an option

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Under each heading, please tick the ONE box that best describes your health TODAY
MOBILITY*

Please select an option

USUAL ACTIVITIES (e.g. work, study, housework, family or leisure activities)*

Please select an option

ANXIETY / DEPRESSION*

Please select an option

SELF-CARE*

Please select an option

PAIN / DISCOMFORT*

Please select an option

If you click the Submit button and nothing appears to happen please check that you have filled out all the mandatory fields.

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