Self Referral Form for Hillingdon
V2
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.
We are not able to provide immediate support in an emergency. If you require immediate help please contact your GP, or your local Accident & Emergency Department, or call the Urgent Advice Line on 0800 0234 650 open 24 hours.
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 to you regarding confidential information.
Title
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
First Name
Last Name
Date of Birth
Gender
Male
Female
Not specified
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 Details
GP Name
GP Surgery Name
GP Surgery Address
Referral Information
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 a long term medical condition? E.g. cancer, stroke, diabetes.
Please Select A Value...
Yes
No
Don't Know/Not Sure
Do not wish to say
If yes, please describe:
Is there anything you would like us to know?
How did you hear about us?
Please complete the captcha
Submit
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