1. Organisation Please select Adult Social Care African and Caribbean Mental Health Service Ailsa Craig Medical Practice Aleeshan Medical Centre Alexandra Park Health Centre Al-Shifa Medical Centre Ancoats Primary Care Centre Ancoats Urban VIllage Medical Practice Artane Medical Centre Ashcroft Surgery Ashville Surgery BabyClear Scheme Baguley Clinic Barlow Medical Centre Be Well Team Beacon Medical Centre Benchill Medical Practice Big Life Group Bodey Medical Centre Boundary House Medical Centre Bowland Medical Practice Broadhurst Children's Centre Brookdale Surgery Brooklands Medical Practice Brooks Bar Medical Centre Brownley Green Health Centre Buccleuch Lodge Intermediate Care Burnage Healthcare Practice Bury Sport and Physical Activity Service Buzz Team Central Manchester University Hospitals NHS Foundation Trust Chadderton Medical Practice Charlestown Medical Practice Cheetham Hill Job Centre Plus Cheetham Hill Primary Care Centre Choose to Change Chorlton Family Practice Citizens Advice Manchester City Health Centre Claremont Resource Centre Clayton Health Centre Community Adult Learning Disabilities Health Team Community Learning Disability Team Conran Medical Centre COPD Support Team Corkland Road Medical Practice Cornbrook Medical Practice Cornerstone Family Practice Cornishway Group Practice Dam Head Medical Centre David Medical Centre Demo Surgery Dickenson Road Medical Centre Didsbury Job Centre Didsbury Medical Centre Disability Team Droylsden Road Family Practice Drs Chiu, Koh & Gan Early Help Hub Eastlands Medical Practice Fallowfield Medical Centre Fernclough Surgery Five Oaks Family Practice Florence House Medical Practice Forum Health Gorton Medical Centre Gorton Parks Intermediate Care Unit Grace Preston Great Places Housing Association Greater Manchester Mental Health Trust Harpurhey District Office. Harpurhey Health Centre Hawthorn Medical Centre Hazeldene Medical Centre High Impact Primary Care Service Higher Openshaw Primary Care Centre Information Support Manchester Integrated Community Rehabilitation Service Job Centre Plus Jolly Medical Centre Khizra Mosque Kingsway Medical Practice Ladybarn Group Practice Later Life Team Learning Disability Team Adults Leg Circulation Service Levenshulme Health Centre Lime Square Medical Centre Livewell Tameside Longsight Health Centre Longsight Medical Practice Manchester Bangladeshi Womens Project Manchester Carers Manchester City Council Manchester Customer Service Centre Manchester Diabetes Centre Manchester Early Intervention Service – South Team Manchester Early Intervention Service – South Team Manchester Medical Manchester Mental Health & Social Care Trust Manchester Royal Infirmary Manchester Shared Lives Mauldeth Medical Centre Merseybank Surgery Mobile Health Screening Unit MoreLife MoreLife Moss Side Medical Centre Motiv8 Manchester Mount Road Surgery New Bank Health Centre New Collegiate Medical Centre New Islington Medical Practice Newbury Green Medical Practice Newton Heath Job Centre Newton Heath Medical Centre NHS Health Checks North Manchester General Hospital North West CATS service (Pain Management) Northenden Group Practice Northern Moor Medical Practice Northwards Housing Association One Manchester Housing Openshaw Job Centre Park View Group Practice Park View Medical Centre Parkside Surgery PARS Pathways CIC Peel Hall Medical Practice People First Housing Association Plant Hill Clinic Princess Road Surgery Queens Medical Centre RK Medical Practice Rusholme Health Centre Saint Mary's Hospital Salford Royal Hospital Salford University: Health Hub Seetec Manchester Self Help Services Self Referral Simpson Medical Practice Sophie Sullivan St Georges Medical Centre St Margarets School Stroke Association Studio - one Supported Living Home Sure Start Centres Surrey Lodge Group Practice Thackers Pharmacy The Alexandra Practice The Arch Medical Practice The Avenue Medical Centre The Borchardt Medical Centre The Christie NHS Foundation Trust The Doc's Surgery The Gaddum Centre The Growth Company The Manchester College Harpurhey Campus The Maples Medical Centre The Mazhari & Khan Practice The Neville Family Pactice The Pankhurst Centre The Park Medical Centre The Range Medical Centre The Robert Darbishire Practice The Royal Oldham Hospital The Singh Medical Practice The Vallance Centre The Whitswood Practice TLC St Lukes Trafford General Hospital Tregenna Group Practice Valentine Medical Centre Victoria Mill Medical Practice Volunteer centre Manchester Wellfield Medical Centre West Gorton Medical Centre West Point Medical Centre Whitley Road Medical Centre Wilbraham Surgery Willowbank Surgery Wilmslow Road Surgery Withington Community Hospital Woodlands Medical Practice Woodville Sure Start Centre Wythenshaw Forum Leisure Centre Wythenshawe Health Care Centre Wythenshawe Hospital Wythenshawe Job Centre Zion Community Resource Centre - You First Other

1. Prefix ^* Please select Mr Mrs Ms Miss Dr Prof Other
2. First Name ^*
3. Middle Names
4. Surname ^*
5. Home Address ^*
6. Town ^*
7. Postcode ^*
   
8. Date of Birth (dd/mm/yyyy)^*
   
9. Telephone ^*
10. Mobile
11. Email
12. Gender ^* Please select Not known Male Female Transgender In another way Not stated
13. NHS Number ^*

1. GP's Practice Please select Ailsa Craig Medical Practice Aleeshan Medical Centre Alexandra Park Health Centre Al-Shifa Medical Centre Ancoats Primary Care Centre Ancoats Urban VIllage Medical Practice Artane Medical Centre Ashcroft Surgery Ashville Surgery Baguley Clinic Barlow Medical Centre Beacon Medical Centre Benchill Medical Practice Bodey Medical Centre Boundary House Medical Centre Bowland Medical Practice Brookdale Surgery Brooklands Medical Practice Brooks Bar Medical Centre Brownley Green Health Centre Burnage Healthcare Practice Chadderton Medical Practice Charlestown Medical Practice Cheetham Hill Primary Care Centre Chorlton Family Practice Citizens Advice Manchester City Health Centre Clayton Health Centre Conran Medical Centre Corkland Road Medical Practice Cornbrook Medical Practice Cornerstone Family Practice Cornishway Group Practice Dam Head Medical Centre David Medical Centre Demo Surgery Dickenson Road Medical Centre Didsbury Medical Centre Droylsden Road Family Practice Drs Chiu, Koh & Gan Eastlands Medical Practice Fallowfield Medical Centre Fernclough Surgery Five Oaks Family Practice Florence House Medical Practice Forum Health Gorton Medical Centre Gorton Parks Intermediate Care Unit Greater Manchester Mental Health Trust Harpurhey Health Centre Hawthorn Medical Centre Hazeldene Medical Centre High Impact Primary Care Service Higher Openshaw Primary Care Centre Jolly Medical Centre Khizra Mosque Kingsway Medical Practice Ladybarn Group Practice Leg Circulation Service Levenshulme Health Centre Lime Square Medical Centre Longsight Health Centre Longsight Medical Practice Manchester Diabetes Centre Manchester Medical Mauldeth Medical Centre Merseybank Surgery Moss Side Medical Centre Mount Road Surgery New Bank Health Centre New Collegiate Medical Centre New Islington Medical Practice Newbury Green Medical Practice Newton Heath Medical Centre Northenden Group Practice Northern Moor Medical Practice Park View Group Practice Park View Medical Centre Parkside Surgery Peel Hall Medical Practice Plant Hill Clinic Princess Road Surgery Queens Medical Centre RK Medical Practice Rusholme Health Centre Simpson Medical Practice St Georges Medical Centre Surrey Lodge Group Practice The Alexandra Practice The Arch Medical Practice The Avenue Medical Centre The Borchardt Medical Centre The Doc's Surgery The Maples Medical Centre The Mazhari & Khan Practice The Neville Family Pactice The Park Medical Centre The Range Medical Centre The Robert Darbishire Practice The Singh Medical Practice The Vallance Centre The Whitswood Practice Tregenna Group Practice Valentine Medical Centre Victoria Mill Medical Practice Wellfield Medical Centre West Gorton Medical Centre West Point Medical Centre Whitley Road Medical Centre Wilbraham Surgery Willowbank Surgery Wilmslow Road Surgery Woodlands Medical Practice Wythenshawe Health Care Centre Other

1. GP's Name

Does your client have any additional needs?

1. Autistic Spectrum Disorders (ASD)
2. Hearing impairment
3. Learning disability
4. Physical disability
5. Visual impairment
6. Difficulty with physical co-ordination
7. Interpreter (English is a second language)
8. Mental health issues
9. Speech impairment
10. Prefer not to answer
11. Other

Will you or a colleague be accompanying your client to their appointments with us?

1. Accompanied

1. How did your client hear about the service? Please select buzz website buzz leaflet Doctor’s surgery Drop in session Drug and Alcohol Advice Services Early Help Hubs Improving Access to Psychological Therapies (IAPT) Neighbourhood Workers NHS Bulletin / Publication NHS Health Check (for clients 40-74 years) Physical Activity Referral Service (PARS) recommendation Referral from partner agency Wellbeing advisors Word of mouth Other

1. Is there any further information that you wish to provide that will assist us in dealing with your client?