Referral Form

V2

If you need to speak to someone urgently please self-refer via the 24 hour Urgent Advice helpline on 0800 0234 650 and not through this self-referral form.

In order to be eligible for the Hillingdon service, you need to be aged 18 years and over and you must be registered with a Hillingdon GP. Please be aware that we are not an urgent service and therefore there may be some wait to be seen. If you have recently attempted suicide, are feeling suicidal, or unable to keep yourself safe, please call our urgent advice line (0800 0234 650) so that more timely support can be arranged for you. This line is open 24hrs a day. Alternately, you can contact your GP for an urgent review of your care or visit your local Accident & Emergency Department.

This self-referral form is a way for you to access psychological support and advice from your local talking therapies service. The service is for people who are having emotional difficulties and are struggling to cope with everyday life. If you have a history of serious mental health issues or drug and alcohol problems it is possible we’re not best suited to help you and we suggest you go to your GP for advice.

Through completing this form you are consenting to have this information stored confidentially on a secure electronic system separate from your GP’s system. Please also note that the information you share with our service is treated confidentially. However, if you disclose information concerning risk to your safety or the safety of others, including children, we are obliged to consult colleagues in Health or Social Care with responsibilities to safeguard you or others. Risk can include physical, emotional, psychological or domestic abuse including controlling behaviour or domestic abuse witnessed by children. We will always inform you when such concerns arise and work collaboratively to obtain your consent to share information. It remains our responsibility to report safeguarding concerns without your consent, where necessary, in our professional capacity when there are real concerns. Your GP will be informed of your contact with our service.

If you are unable to complete this form for any reason or if you would prefer to give these details over the phone please call or email your local service.

By providing these details you are giving us consent to contact you regarding confidential information.

Title*

First Name*

Last Name*

Date of Birth*

Gender*

Are you able to have your appointments in English?*

Yes

No

If you have selected No, please specify the language (including BSL), and we will organise an assessment with an interpreter (please note that we use professional interpreters and will not use family members/friends to interpret for you).

Please select language:

Address Line 1*

Address Line 2

Town/City*

County*

Postcode*

Home Number

Can we leave a voicemail?

Yes

No

Mobile Number

Can we leave a voicemail?

Yes

No

Can we send you text message reminders?

Yes

No

Please note that, whilst NHS email is secure, we cannot guarantee that your own email server will be so. Please only give us your email if you are happy for confidential information to be sent to your email address.

Email*

Can we correspond with you via email?*

Yes

No

GP Name

GP Surgery Name*

GP Surgery Address*

We ask these questions to ensure that our service is being accessed by everyone and to ensure any specific requirements are met.

Ethnicity

Sexuality

Disability

If Other, please specify

Are you an NHS or social care front line worker?

Yes

No

Are you, or your partner, pregnant or do you have any children under 1 or under 5?

Please describe the problem you need help with:*

Have you ever received treatment for these difficulties?*

Yes

No

Please describe any treatment or support you’ve had for these difficulties:

What type of help are you looking for?*

Are you unemployed, and would like to receive employment support getting back into work?

Yes

No

Do you have any long-term medical conditions?*

If Other, please specify

Is there anything you would like us to know?*

Where did you hear about us?*

If other, please specify

Please complete the captcha

Self Referral Form for Hillingdon

GP Details

Further Information

Referral Information