Accelerator Self Referral Form

Surname

First name

Address 1

Address 2

Address 3

Postcode

Email address

Date of birth

Phone number

Ethnicity Ethnicity Which of the following options best describes your race, ethnic or cultural origin: White English / Welsh / Scottish / Northern Irish / British White Irish White East European White Other Mixed White / Black Caribbean Mixed White / Black African Mixed White / Asian Mixed Other Asian or Asian British Indian Asian or Asian British Pakistani Asian or Asian British Bangladeshi Asian or Asian British Kashmiri Asian or Asian British Other Black or Black British Caribbean Black or Black British African Black or Black British Other Chinese Roma Arab Gypsy / Traveller Other Don’t Know

Job Title

Employer

Are you living with long-term pain? Are you living with long-term pain? Yes No

Do you consider yourself to have a disability? Do you consider yourself to have a disability? Yes No

Please describe:

Are you actively going into work/working remotely? Are you actively going into work/working remotely? Yes No

Tell us a little about your employment situation. For example: What sort of contract are you on? What are the pain-related struggles you encounter when working? Have you been signed off sick before?

Date of your last day at work

Tell us a little about your employment situation. For example: How did your employer try to help you with your pain? How do you feel about being signed off sick from work? How do you feel about returning to work?

MUST be completed for referral to be accepted. MUST be completed for referral to be accepted. I consent to my name, contact details and the personal information on this form being stored securely in compliance with GDPR requirements. Details will be stored for 60 months as outlined in the relevant privacy policy