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* 1. As part of the system-wide Best-Fit Practitioner initiative, we are building a comprehensive overview of self-referral services available across our system. Self-referral services are those that individuals can access directly when they have a health need. Your responses will help us understand:

1) What these services are
2) Who provides them
3) How people can access them
4) Who is eligible

Estimated completion time: 5-7 minutes.
Thank you for your valuable input.

If you have any questions about this form or need assistance, please contact Jayne Chambers, Transformation Team, at jaynechambers@nhs.net

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* 2. Service Name?
Please provide the official and full and correct name of the service.

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* 3. Who provides this service?
Select the main provider responsible for this service.

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* 4. Is this service part of a NHS National Programme?
If yes, please specify which one.

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* 5. Does your service provide self-referral options?

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* 6. How can people access your self-referral service?
Select all that apply.

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* 7. Who is eligible to use your self-referral service?
Please describe the eligibility criteria (e.g., age, location, specific conditions). If none write "none".

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* 8. Are there any restrictions or exclusions for self-referral?
If yes, please detail any restrictions (e.g., specific populations, conditions not covered). If none, write “None”.

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* 9. Please provide a brief description of your service.
Summarise the main purpose and key features of the service.

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* 10. Does the service you provide have any plans for future self-referral pathways?

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* 11. If you answered Yes or Maybe above, please provide the name of the future self-referral pathway or service.

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* 12. Who will provide the future self-referral service?
Select the main provider.

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