Referral Form

V2

Please note, this form is only to be completed by the person seeking help from NHS Talking Therapies.

We cannot accept referrals from third parties online (including friends and family).

If you are a health professional and you would like to make a referral, please contact the local team (please see www.lscft.nhs.uk/talking-therapies/contact-us for contact details)

Our service offers treatment for mild to moderate common mental health problems such as anxiety and depression. Please be mindful that it is not an urgent care or crisis service and your responses on this form may not be seen until you are booked in to speak to a clinician. If you are feeling unsafe please call our Mental Health Crisis Line which is available 24 hours a day, 7 days a week by calling 0800 953 0110.

NHS Lancashire and South Cumbria Talking Therapies cover the following GP practice areas in Lancashire (Blackburn With Darwen, Chorley South Ribble, East Lancs, Fylde & Wyre, Greater Preston, Morecambe Bay and West Lancs).

Please note the Furness & South Lakes teams only see adults (18+) who are registered with GP Practices within the area. If you are younger than 18 or registered with a practice outside these areas please contact your GP or visit www.nhs.uk for details of similar services to meet your needs.

If these are not an area that you are registered with please visit: www.nhs.uk to find your local talking therapies service

Are you aged 16 or over (18 or over for South Cumbria) and registered with a GP practice in Lancashire or South Cumbria?*

Yes

Title*

First Name*

Last Name*

Date of Birth*

Gender*

Is your gender the same as it was at birth?*

Address Line 1*

Address Line 2

Town/City*

County*

Postcode*

Please leave at least one contact number below.

Mobile Phone Number

Permission to Leave Voicemail on Mobile Phone?

Yes

No

Permission to Send Text Message Reminders?

Yes

No

Alternative Phone Number

Phone Type

Permission to Leave Voicemail on Alternative Phone?

Yes

No

Initial Contact - Preferred Day*

Initial Contact - Preferred Time of Day*

Morning

Afternoon

NB: We will do our best to match the time of day selected, however not all teams have the capacity to offer evening appointments.

Email

(please only add if you are happy for us to contact you via email when necessary and to send correspondence to this address)

GP Practice Name*

GP Phone Number*

Please tick the box(es) that are relevant to your mental health at the moment:*

If you have ticked PTSD, does this relate to:

A single traumatic event

Several traumatic events

Please select how long your difficulties have been ongoing:*

Less than 3 months

3-12 months

1-2 years

Two or more years

Please note that we are not a diagnostic service (for example we do not provide diagnostic assessments of Autism, ADHD, Learning Disability or specific Mental Health diagnoses such as Bipolar Disorder).

Are you currently in education?*

Preferred Language*

Do you have any communication needs we should be aware of?

Do you have a Communication Passport?

Yes

No

Are there any reasonable adjustments we need to be made aware of?

Yes

No

If yes, please specify:

Please specify any details we need to be aware of such as Font Size, Language for translation, etc.

Nationality*

Ethnicity*

Religion*

Sexual Orientation*

Disability*

Do you have any Long Term Medical Conditions?*

If yes, please select

Is this referral related to your long term condition?

Yes

No

Do you have any Mobility Issues?*

Yes

No

Please state if you have recently been involved in a traumatic event:*

Yes

No

Are you or your partner currently pregnant, or have you had a child in the last 24 months?*

Yes

No

With relation to the British Armed Forces, are you*

Next of Kin/Emergency Contact Name*

Next of Kin/Emergency Contact Number*

Next of Kin/Emergency Contact Relationship to you*

Where did you hear about the service?*

Have you received or are you currently receiving any support from mental health services?

Yes

No

Have you completed this form yourself?*

Yes

No

The NHS regularly takes part in research on how to improve the experience of patients and the effectiveness of treatment. Please tick yes if you are be willing to allow our researchers to contact you about participating in future research. You can withdraw your consent at any time. If a researcher contacts you will be asked for your consent again before taking part in research.

Please tick here:*

Yes

No

NHS Talking Therapies is not an urgent service and cannot support people who are in crisis, if you need urgent support please find your local services here www.lscft.nhs.uk/talking-therapies/useful-resources

Please tick to confirm that you have understood this:*

Yes

I consent to you contacting the relevant GP or other services for further information if required in line with NHS Confidentiality agreements. I am aware information will be stored on a database.

By ticking this box, I confirm my consent as stated above*

Yes, I consent

Please complete the captcha

Self Referral Form

Personal Details

GP Details

Further Information