NEL physiotherapy self referral

Welcome to the Ascenti self-referral form for patients registered with a North East Lincolnshire GP practice.

Our team will assess your referral to ensure you are on the most suitable treatment journey for your injury or condition. Once your referral has been reviewed we will call you to arrange your first appointment. 

If you are considering physiotherapy as a treatment option for your current symptoms, we recommend first visiting the NHS physiotherapy page

Here you will find an overview of what physiotherapy is and when it can be used to help people with bone, joint and soft tissue complaints. You will also find some useful self-care advice that may assist in your recovery without the need to see a physiotherapist.

To use this service you must be a patient registered with a North East Lincolnshire GP practice and be 16 years of age or older.

COVID-19 update: All patients will receive a virtual initial assessment, either via our Ascenti Physio app or verbal telephone conversation. Following your first virtual appointment your therapist will discuss the next steps and whether face-to-face treatment is necessary. If you have communication needs which will restrict this approach please include this information in the form below. 

Eligibility for self-referral 

To be eligible for self-referral you must not suit any of the following points, if so please discuss treatment with your GP. 

  • Be under the age of 16 
  • Currently be seeing another NHS community MSK provider for the same condition
  • Have previously had treatment for the same condition within 6 months 
  • Be self-referring for a continuation of treatment beyond 6 sessions 
  • Have missed 2 appointments previously 
  • Be receiving active psychiatric treatment under a Section of the Mental Health Act
  • Have deteriorating neurological conditions or require specialist neurological rehabilitation
  • Require rehabilitation post-surgery 
  • Require healthcare facilities which are not available 
I certify that all information detailed on the attached form is accurate to the best of my knowledge and this information will be shared with the selected GP.

Your details

Do you have any particular communication needs?
Do you require an interpreter for your assessment?
Are you happy for us to leave a voicemail?
Body part affected
How long have your symptoms been present?
My symptoms are...
Pain level today
0 being pain free and 10 being highest possible pain
Have you had treatment for this condition before?
Are you off work due to this problem?
Do you have any other medical history we should be aware of?
Do you currently have any of the following symptoms?
Is your referral for neck pain?
If yes, do you have any of the following symptoms?
Is your referral for lower back symptoms?
If yes, do you have any of the following symptoms?