Referral Form

Patients Details

NHS Number, if known

Title*

First Name*

Last Name*

Gender*

If 'other' is selected, please specify

Date of Birth*

Address Line 1*

Address Line 2

Town/City*

County*

Postcode*

Permission to send written communication to your home?*

Yes

No

Mobile Phone Number*

Permission to send text*

Yes

No

Permission to leave a voicemail*

Yes

No

Please note that Tower Hamlets Talking Therapies will be calling from a withheld/private number. We will only leave a message if you have given us permission to do so.

Home Phone Number

Email*

Permission to contact by email?*

Yes

No

Please share the details of someone we can contact in the event of an emergency. We would only ever contact this individual where we have concerns about yourself in order to help you find the correct immediate support and this is a requirement to be seen within our service.

First name*

Last Name*

Telephone*

Relationship*

National Identity

Ethnicity

Religion

Able to communicate in spoken English?

Yes

No

Understands written English?

Yes

No

Do you require an interpreter / translator?*

Yes

No

If Yes, please specify which language

Relationship Status

Sexual Orientation

Disability Status

Do you have any long term medical conditions?

If other, please specify:

Are you a carer? A carer is anyone who cares, unpaid, for a family member or friend who due to illness, disability, a mental health problem or an addiction, cannot cope without their support.

Yes

No

Are you pregnant or do you have a child under 12 months?

Yes

No

Tower Hamlets talking therapies offers employment support alongside therapy, this can be to help find work or remain in work. Is this something you would be interested in?*

Yes

No

We are always looking to enhance our service for future service users. Once you have completed your treatment would you consent for us to contact you by telephone/email to understand your experience of using our service?*

Yes

No

GP Practice*

By referring yourself to this service you are agreeing that the service may contact and share relevant information with your GP to facilitate your care

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Self Referral Form

Patients Details

Address

Contact Details

Emergency Contact Details

Demographics

Registered GP Details