Register for Outlook South West

Personal Details

We email questionnaires to you during your treatment. These are used to review your progress. They are sent and received securely.

GP Details

Referral Information

Please be aware that we are not an emergency service. If you feel that you are in crisis or in need of urgent support, please contact your GP or 24/7 NHS Mental Health Response line 0800 038 5300

Assessment Questionnaires

Please answer every question in the below questionnaires - this should take about 10 minutes to complete and is an essential part of your assessment for treatment. The questionnaires will help us identify symptoms of low mood and/or anxiety.

PHQ-9

Over the last 2 weeks, how often have you been bothered by any of the following problems?*
PHQ-9 is adapted from PRIME MD TODAY, developed by Drs Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer Inc. For research information, contact Dr Spitzer at rls8@columbia.edu. Use of the PHQ-9 may only be made in accordance with the Terms of Use available at http://www.pfizer.com. Copyright 1999 Pfizer Inc. All rights reserved. PRIME MD TODAY is a trademark of Pfizer Inc.

If you answered either More Than Half the Days or Nearly Every Day to Question 9 above, please complete the following questions

GAD-7

Over the last 2 weeks, how often have you been bothered by any of the following problems?*
The GAD-7 originates from Spitzer RL, Kroenke K, Williams JB, et al; A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006 May 22;166(10):1092-7. GAD-7 © Pfizer Inc. all rights reserved; used with permission.

Work & Social Adjustment

People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems look at each section and decide on the scale provided how much your problem impairs your ability to carry out the activity.
Ref: Mundt, J. C., I. M. Marks, et al. (2002). "The Work and Social Adjustment Scale: a simple measure of impairment in functioning." Br J Psychiatry 180: 461-4.

Phobia Scales

Choose a number from the scale below to show how much you would avoid each of the situations or objects.
The IAPT Phobia Scale is reproduced from the IAPT Toolkit which is ©Crown copyright. Reproduced under the terms of the Open Government Licence which can be found at http://www.nationalarchives.gov.uk/doc/open-government-licence/version/1/open-government-licence.htm

Further Information

Thank you for completing the above details. One of our therapists will review your information within the next 5 working days and advise, by email or letter, which treatment will be most suited for your needs.
Please indicate below if you have a particular preference for one of our wellbeing courses and/or online programmes. If you do not select a preference, we will offer you the most suitable course or programme for your difficulties at this time:
In some cases we may recommend one-to-one therapy, although you may need to wait for this option.
In some cases we may recommend one-to-one therapy, although you may need to wait for this option. We will send you an email or letter advising that you have been placed on our waiting list for one-to-one therapy and you will receive an appointment by post or email to start your treatment as soon as we have an appointment for you.
Please be aware that if you cancel or miss 2 appointments throughout your care with OSW, you will be discharged and will need to re-refer when you are able to attend appointments.

Use of Information

By submitting this online referral form, you are agreeing to share your data with the NHS. For more information on how we collect, store and use your data – please see below (copy and paste the url into a new tab or window)
https://www.cornwallft.nhs.uk/download.cfm?doc=docm93jijm4n9284&ver=29044