Self referral form

Welcome to the self referral section of our website. While self referral to physiotherapy is appropriate for the majority of people, there are some exceptions where we would ask that you see a Doctor first.

If you have a significant past medical history of cancer, or are currently undergoing treatment for cancer you should make an appointment to see your GP to discuss a physiotherapy referral.
If you are experiencing back pain AND have any of the following symptoms: •tingling or numbness between your legs and around your buttocks •recent loss of bladder or bowel control, or both

You should IMMEDIATELY attend the Emergency Department of your local hospital.

Although it's rare, these symptoms can be a sign of a serious condition called cauda equina syndrome.

To proceed with the physiotherapy self referral system tick the box below

Proceed

If you are considering self referring to physiotherapy did you know that a lot of the early advice a physiotherapist would give you is available on our website?

We have organised this into three useful sections:

Advice on new pain problems
Advice on managing a long term pain problem (such as back pain or arthritis)
A directory of common conditions with early management advice for each one.

I have not yet accessed the physiotherapy advice on the website

I have accessed the physiotherapy advice on the website and still need to self refer

You can self refer for physiotherapy treatment if:

-You are over the age of 17+

-You are registered with a Vale of York CCG

-You have a musculoskeletal pain problem (self referral isn't available for mobility rehabilitation, neurological problems, or continence rehabilitation)

If you have a personal history of cancer please do not use the self referral form, you should see your GP in the first instance

Self referral form

Please select a GP's Practice:

Links page

Name

Address

Age/Date of Birth

Contact Details

More information