Turn the Page: Self Referral FormIf you are under 16, a parent or guardian will need to fill this in for you. Name * First Name Last Name Your Preferred Name Date of Birth * MM DD YYYY Address * Contact Number * Email * How would you like us to contact you? Phone, text, email GP Practice you are registered with Gender * Ethnicity * Do you identify with any of the following? * Diagnosed mental health condition Anxiety and/or depression Perceived poor mental health Low confidence or self-esteem Physical health challenge Change in circumstances Bereavement Social isolation Other N/A What would you like to get out of taking part in Turn the Page? This could include things like meeting new people, learning about comics, feeling happier or less anxious, improving your mental health, having a space to talk about you feel, increasing your confidence, or working on your self care skills. Is there anything you need specific help with? What activities would you like to try? For example, this could be 1-2-1 support sessions via Microsoft Teams, making comics or zines, learning about drawing, etc What do you enjoy doing in your spare time? This could include things that interest you like reading certain books or comics, watching TV shows, playing video games, building things, drawing, creating, football, drama, etc Parent or Guardian Contact Name * Parent or Guardian Contact Phone Number * Parent or Guardian Contact Email * Thank you for taking the time to fill in your self-referral! Our working week is Tuesday-Friday, and someone will be in touch with you within 5 working days.
