Self Referral Form
V2
V2
Please note, this form is only to be completed by the person seeking help from NHS Talking Therapies.
We cannot accept referrals from third parties online (including friends and family).
If you are a health professional and you would like to make a referral, please contact the local team (please see www.lscft.nhs.uk/talking-therapies/contact-us for contact details)
Our service offers treatment for mild to moderate common mental health problems such as anxiety and depression. Please be mindful that it is not an urgent care or crisis service and your responses on this form may not be seen until you are booked in to speak to a clinician. If you are feeling unsafe please call our Mental Health Crisis Line which is available 24 hours a day, 7 days a week by calling 0800 953 0110.
NHS Lancashire and South Cumbria Talking Therapies cover the following GP practice areas in Lancashire (Blackburn With Darwen, Chorley South Ribble, East Lancs, Fylde & Wyre, Greater Preston, Morecambe Bay and West Lancs).
Please note the Furness & South Lakes teams only see adults (18+) who are registered with GP Practices within the area. If you are younger than 18 or registered with a practice outside these areas please contact your GP or visit www.nhs.uk for details of similar services to meet your needs.
If these are not an area that you are registered with please visit: www.nhs.uk to find your local talking therapies service
Are you aged 16 or over (18 or over for South Cumbria) and registered with a GP practice in Lancashire or South Cumbria?*
Yes
Personal Details
Title*
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
First Name*
Last Name*
Date of Birth*
Gender*
Male (including trans man)
Female (including trans woman)
Gender Non-binary
Intersex
Not specified
Other (not listed)
Is your gender the same as it was at birth?*
Please Select A Value...
Yes
No
Not Known
Not Stated
Address Line 1*
Address Line 2
Town/City*
County*
Postcode*
Please leave at least one contact number below.
Mobile Phone Number
Permission to Leave Voicemail on Mobile Phone?
Yes
No
Permission to Send Text Message Reminders?
Yes
No
Alternative Phone Number
Phone Type
Please Select a Value...
Home Phone
Work Phone
Other Phone
Permission to Leave Voicemail on Alternative Phone?
Yes
No
Initial Contact - Preferred Day*
Monday
Tuesday
Wednesday
Thursday
Friday
Initial Contact - Preferred Time of Day*
Morning
Afternoon
NB: We will do our best to match the time of day selected, however not all teams have the capacity to offer evening appointments.
Email
(please only add if you are happy for us to contact you via email when necessary and to send correspondence to this address)
GP Details
GP Practice Name*
GP Phone Number*
Further Information
Please tick the box(es) that are relevant to your mental health at the moment:*
Low mood/Depression
Social Anxiety
Generalised anxiety/worry
Panic attacks
Post-traumatic Stress Disorder (PTSD)
Obsessive Compulsive Disorder (OCD)
A specific fear or phobia
Bereavement and loss
If you have ticked PTSD, does this relate to:
A single traumatic event
Several traumatic events
Please select how long your difficulties have been ongoing:*
Less than 3 months
3-12 months
1-2 years
Two or more years
Please note that we are not a diagnostic service (for example we do not provide diagnostic assessments of Autism, ADHD, Learning Disability or specific Mental Health diagnoses such as Bipolar Disorder).
Are you currently in education?*
Please Select A Value...
School
College
University
Other Educational Establishment not listed
Not Applicable (not a student)
Not stated
Not known
Preferred Language*
Please Select A Value...
English
Akan (Ashanti)
Albanian
Amharic
Arabic
Bengali & Sylheti
Bosnian
Brawa & Somali
British Signing Language
Bulgarian
Cantonese and Vietnamese
Chinese
Creole
Czech
Dutch
Ethiopian
Farsi (Persian)
Finnish
Flemish
French
Gaelic
German
Greek
Gujarati
Hausa
Hebrew
Hindi
Igbo (Ibo)
Italian
Japanese
Korean
Kurdish
Latvian
Lingala
Lithuanian
Luganda
Macedonia
Madagascan
Makaton (sign language)
Malayalam
Malaysian
Norwegian
Pashto (Pushtoo)
Persian
Polish
Portuguese
Punjabi
Romanian
Russian
Scottish
Serbian/Croatian
Sinhala
Somali
Spanish
Swahili
Swedish
Tagalog (Filipino)
Tamil
Thai
Tigrinya
Turkish
Ukrainian
Urdu
Vietnamese
Welsh
Yoruba
Other
Do you have any communication needs we should be aware of?
Large Print Documents
Language Translation Service
British Sign Language interpreter
Hearing loop facility area
Other details
Do you have a Communication Passport?
Yes
No
Are there any reasonable adjustments we need to be made aware of?
Yes
No
If yes, please specify:
Please specify any details we need to be aware of such as Font Size, Language for translation, etc.
Nationality*
Please Select a Value...
English
Scottish
Welsh
Irish
British
Other
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 - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
Religion*
Please Select A Value...
No religious group or secular
Atheist / Agnostic
Church of England
Other protestant
Orthodox Christian
Roman Catholic
Other Christian
Muslim
Shi'ite Muslim
Sunni Muslim
Sikh
Jewish
Orthodox Jewish
Buddhist
Hindu
Jain
Zoroastrian
Rastafarian
Any other religion
Not stated
Sexual Orientation*
Please Select A Value...
Heterosexual
Lesbian or gay
Bisexual
Other
Not known
Not stated
Unknown
Disability*
Please Select a Value...
No Disability
Autism
Behaviour and Emotional
Hearing
Learn or understand (Learning Disability)
Manual Dexterity
Memory or ability to concentrate
Mobility and Gross Motor
Perception of Physical Danger
Personal, Self Care and Continence
Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits, etc)
Sight
Speech
Other
Do not wish to say
Do you have any Long Term Medical Conditions?*
Please Select a Value...
Yes
No
Don't Know/Not Sure
Do not wish to say
If yes, please select
Asthma
Cancer
Chronic Fatigue Syndromes/Myalgic Encephalopathy (ME)
Chronic Pain
Diabetes
Digestive Tract Conditions
Epilepsy
Heart Failure
Medically Unexplained Symptoms
Musculoskeletal Disorder (MSK)
Respiratory Disease
Skin condition including Eczema
Is this referral related to your long term condition?
Yes
No
Do you have any Mobility Issues?*
Yes
No
Please state if you have recently been involved in a traumatic event:*
Yes
No
Are you or your partner currently pregnant, or have you had a child in the last 24 months?*
Yes
No
With relation to the British Armed Forces, are you*
Please Select a Value...
Dependant of a ex-services member
Not an ex-services member or their dependant
Do not wish to say
Not known or Not Sure
Ex-services member
Next of Kin/Emergency Contact Name*
Next of Kin/Emergency Contact Number*
Next of Kin/Emergency Contact Relationship to you*
Please Select A Value...
Brother
Carer
Child
Civil Partner
Cousin
Dependant
Father
Father in law
Foster Parent
Grandmother
Grandfather
Guardian
Husband
Mother
Mother in law
Nephew
Niece
Next of Kin
Non-dependant
Not Known
Other
Partner
Relative
Sister
Spouse
Step Brother
Step Father
Step Mother
Wife
Where did you hear about the service?*
Please Select A Value...
Advertisement
A&E
Colleague
College/Further Education
County Council
Employer
Employment Services
Friend
Family Member
GP
Wellbeing Helpline
Other Service
Other not specified
School
Social Media
Social Services
University
Have you received or are you currently receiving any support from mental health services?
Yes
No
Have you completed this form yourself?*
Yes
No
The NHS regularly takes part in research on how to improve the experience of patients and the effectiveness of treatment. Please tick yes if you are be willing to allow our researchers to contact you about participating in future research. You can withdraw your consent at any time. If a researcher contacts you will be asked for your consent again before taking part in research.
Please tick here:*
Yes
No
NHS Talking Therapies is not an urgent service and cannot support people who are in crisis, if you need urgent support please find your local services here www.lscft.nhs.uk/talking-therapies/useful-resources
Please tick to confirm that you have understood this:*
Yes
I consent to you contacting the relevant GP or other services for further information if required in line with NHS Confidentiality agreements. I am aware information will be stored on a database.
By ticking this box, I confirm my consent as stated above*
Yes, I consent
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