Psychosexual Therapy Patient Request Form
This service is available to residents of Doncaster and Mexborough who are registered with a Doncaster-based GP.
Full Name:
*
First Name
Last Name
Date of Birth
*
-
Day
-
Month
Year
Date Picker Icon
Sex at Birth:
*
Gender:
*
Country of Birth:
*
Patient Contact Number :
*
Mobile/ Landline
Format: (00000) 000000.
Home Address:
*
Street Address
Street Address Line 2
City
County
Postcode
Email
*
example@example.com
Do you require an interpreter
*
Yes
No
Language required:
GP Address:
*
Practice Name
Street Address Line 2
City
County
Postcode
No registered GP :
Yes
Patient consents to information sharing with other professionals involved in their care e.g. GP, MHAT, IAPT, Hospital etc :
*
Yes
No
A brief description of your sexual difficulty eg: erectile/ejaculation difficulties, pain during sex, lack of desire for sex etc:
*
Please give permission for us to contact you via :
*
Phone
Voicemail
Text
Email
Letter to home address
An initial assessment will be arranged via a phone call from a withheld number, so please let us know if there are any times when you are unable to take a call.
Please note:
We will acknowledge receipt of referrals by email and will not leave a voicemail unless you have given permission. We will acknowledge receipt of referrals by email and aim to respond to emails within two weeks.
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