Referral Form

Please note that unless you are NHS or social care staff, we can only accept referrals from people aged 16 or over who are registered with a Barnet or Enfield GP surgery.

We are unable to accept referrals if you have a primary alcohol or drug misuse problem, or if you are already being seen by other secondary care or specialist mental health services.

We are also unable to offer immediate crisis support.

Everything you tell us is kept confidential, however if you disclose information concerning current or potential harm or risk to yourself or another person, we will need to inform the relevant agencies/health professionals to ensure that the right support is provided.

We are required to share information with your GP and/or referrer about your referral and treatment, which we may do either verbally or in writing

Once you have filled in this referral form we will be in touch with you in due course, it will be either with a therapist within IAPT or a therapist from one of our partner services, MWS, IESO Digital Health or Xyla Digital Therapy. There can be a further delay if you have specific requirements.

Please confirm that you agree with these terms and conditions:*

Yes

If you are worried about acting on suicidal thoughts OR if you are worried about hearing voices or other psychotic symptoms - Contact your GP or specialist mental health services via The Crisis Resolution and Home Treatment Team on 0800 151 0023.

Have you or your GP submitted a referral form in last 4 weeks?:

Yes

No

If ‘Yes’ then email us on beh-tr.barnettalkingtherapies@nhs.net for Barnet and beh-tr.enfieldtalkingtherapies@nhs.net for Enfield instead of filling this information again.

If you are referring on behalf of someone else, please enter their details below:

Title:*

First Name:*

Last Name:*

Date of Birth:*

Please note we are unable to accept referrals for people who are under 16 years of age. Please contact your GP for advice as to the best service to help you.

Gender:*

Ethnicity:*

Sexuality:*

Preferred Pronouns:

NHS Number:

Address Line 1:*

Address Line 2:

Town/City:*

County:

Postcode:*

Home Number:

OK to leave voice messages on Home Number:

Yes

No

Mobile Number:

OK to leave voice messages on Mobile Number:

Yes

No

We will send a text message with a link to book your first appointment online and for future appointment reminders. If you do not want to receive texts, you will be contacted by letter or email.

I am happy to receive text messages:*

Yes

No

Emails are the fastest way to communicate and questionnaires are sent before your appointment via email. If you do not have an email address or prefer to not receive emails, please indicate below.

OK to communicate via email:*

Yes

No

Email:

Where is your GP practice?*

Barnet

Enfield

Other (only if the referral is for NHS or Social care staff)

GP Practice:*

GP Name:

Please note that your GP and Health Visitor (if applicable) will be kept informed of your referral.

Interpreter required?:*

Yes

No

If yes, in which language?

Are you/your partner pregnant?:

Yes

No

If yes, when is your baby due? Date:

Do you have children under the age of 2?:

Yes

No

Do you have any long term conditions? (select from the list below):*

IF Other, please specify:

Is the main reason for this referral related to long-term health condition(s)?*

Do you have special access requirements?:

Yes

No

IF yes please specify:

Are you currently serving/previously served as a member of the armed forces?:

Please provide the name and contact details of someone we can contact in case of an emergency, such as a family member or friend.

Name:

Relationship:

Mobile number:

What is the main problem that you would like help with, and how is it affecting your life?:*

Are you receiving treatment for the above (or previously received treatment)? Please describe:*

What are your expectations of psychological therapy offered by our service? How would you like things to be different for you?:*

How did you hear about us?:*

If Other, Please specify:

Please complete the captcha

Self Referral Form

Your Details

Perinatal Questions