Self Referral Form
V2
V2
Bromley Talking Therapies is not a crisis service. If you need urgent support please do not complete this form. Instead, please call:
- your GP for an emergency appointment
- the Oxleas Urgent Advice Line on 0800 330 8590
- the Samaritans on 116 123
- 999 or 111, or go directly to your local Accident and Emergency Department
Personal Details
Title
Please Select a Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
First Name*
Last Name*
Date of Birth (DD/MM/YYYY)*
NHS Number (if known)
Gender*
Male
Female
Non binary
Other
Don't Know
Prefer not to say
Preferred Pronouns
Please Select A Value...
She/Her/Her
He/Him/His
They/Them/Their
Ae/Aer/Aer
Ey/Em/Eir
Fae/Faer/Faer
Per/Per/Pers
Ve/Ver/Vers
Xe/Xem/Xyr
Ze/Hir/Hir
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
Are you an NHS or social care front line worker?*
Yes
No
Do you have a long-term medical condition?*
Yes
No
If yes, please specify
Do you have any information and communication needs due to a disability, impairment or sensory loss?*
Yes
No
If yes, please explain
What is the best way to contact you?*
Contact to call in case of emergency, e.g., name of relative, friend or carer
Relationship of this person to you
Emergency contact phone number
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.*
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.
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.
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.*
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