Referral Form

V2

Please be aware that we are not an urgent service and therefore there may be some wait to be seen. If you have recently attempted suicide, are feeling suicidal, or unable to keep yourself safe, please call our urgent advice line (0800 0234 650) so that more timely support can be arranged for you. This line is open 24hrs a day. Alternately, you can contact your GP for an urgent review of your care or visit your local Accident & Emergency Department.

This self-referral form is a way for you to access psychological support and advice from your local talking therapies service. The service is for people who are having emotional difficulties and are struggling to cope with everyday life. If you have a history of serious mental health issues or drug and alcohol problems it is possible we’re not best suited to help you and we suggest you go to your GP for advice.

Through completing this form you are consenting to have this information stored confidentially on a secure electronic system separate from your GP’s system, and for your GP to be informed of your contact with us.

If you are unable to complete this form for any reason or if you would prefer to give these details over the phone please call or email your local service.

By providing these details you are giving us consent to contact you regarding confidential information.

Title

First Name

Last Name

Date of Birth

Gender

Address Line 1

Address Line 2

Town/City

County

Postcode

Home Number

Can we leave a voicemail?

Yes

No

Mobile Number

Can we leave a voicemail?

Yes

No

Can we send you text message reminders?

Yes

No

Please note that, whilst NHS email is secure, we cannot guarantee that your own email server will be so. Please only give us your email if you are happy for confidential information to be sent to your email address.

Email

Can we correspond with you via email?

Yes

No

GP Name

GP Surgery Name

GP Surgery Address

We ask these questions to ensure that our service is being accessed by everyone and to ensure any specific requirements are met.

Ethnicity

Sexuality

Disability

If Other, please specify

Are you an NHS or social care front line worker?

Yes

No

Are you, or your partner, pregnant or do you have any children under 1 or under 5?

Please describe the problem you need help with:

Have you ever received treatment for these difficulties?

Yes

No

Please describe any treatment or support you’ve had for these difficulties:

What type of help are you looking for?

Are you unemployed, and would like to receive employment support getting back into work?

Yes

No

Do you have any long-term medical conditions?

If Other, please specify

Is there anything you would like us to know?

Where did you hear about us?

If other, please specify

Have you had any thoughts of killing yourself in the past two weeks?

Yes

No

Have you made plans to kill yourself in the last two weeks?

Yes

No

Do you think you are likely to act on these plans within the next three days?

Yes

No

Have you made any previous attempts to kill yourself?

Yes

No

Please complete the captcha

Self Referral Form for Hillingdon

GP Details

Further Information

Referral Information