Self Referral Form
V2
V2
We are not a crisis service. If you need urgent support, please do not complete this form. Instead, please:
- contact your GP for an emergency appointment
- contact the Oxleas Urgent Advice Line on 0800 330 8590
- call the Samaritans on 116 123
- call 999
- Or go to your nearest A&E department
Personal Details
Title
Please Select a Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
First Name
Last Name
Please use the calendar to enter your date of birth or type it in the format 00/00/0000
Date of Birth
NHS Number (if known)
Gender
Male
Female
Non binary
Unspecified
Ethnicity
Please Select A Value...
White - British
White - Irish
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Any other Asian background
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Any other Black background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Japanese
Other Ethnic Groups - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
Address Line 1
Address Line 2
Town/City
County
Postcode
Phone Number
Phone Type
Please Select a Value...
Home Phone
Mobile Phone
Work Phone
Other Phone
Permission to leave a message?
Yes
No
Permission to send a text message?
Yes
No
Email
Permission to send an email?
Yes
No
Do you need an interpreter?
Yes
No
If yes, please specify your language
Do you work for the NHS? (for example an NHS Trust, primary care or a charity funded by primary care, CCG etc)
Yes
No
Do you work in Social Care (for example you work for the local authority, in a care home or providing care for residents at home?)
Yes
No
Do you have a long-term medical condition?
Yes
No
If yes, please specify
GP Details
Please note we will inform your GP that we have received this referral.
GP Practice Name
GP Practice Address
Further Information
How did you hear about our service?
Are you pregnant?
Yes
No
Is your partner pregnant?
Yes
No
Are you a parent of a child under 18 years?
Yes
No
Are you a parent of a baby under 12 months?
Yes
No
Are you a military veteran?
Yes
No
Please provide details of any current medication prescribed by your doctor or other health professional, or any other over the counter medication you are currently taking.
Referral Information
Please provide details about your current difficulties including when they started and what symptoms you are experiencing.
If we decide that we are not the right service to offer you therapy, we may send your referral to another service that may be more appropriate for you.
Please confirm that you have understood this
If we have concerns about your safety, or the safety of others, we have a duty of care to liaise with appropriate health and social care professions to ensure that the necessary support is arranged.
Please confirm that you have understood this
Are you currently receiving help, support or therapy from any other service?
Yes
No
If yes, please provide details.
Have you ever had contact, help, support or therapy from any other service?
Yes
No
If yes, please provide details.
Have you been diagnosed with a mental health problem in the past or present?
Yes
No
If yes, please provide details.
In order to reduce your wait for the service, we now work in partnership with Xyla Digital Therapies. This service offers timely assessments and treatments.
Do you consent to being contacted by this service if appropriate?
Yes
No
Please be aware a therapist may call you to discuss your referral. Failure to speak to you may result in your referral not being processed. Please note our calls show as a withheld number. If we can’t contact you we will contact your GP.
Please complete the captcha
Submit
Cancel