Referral Form

Please note that in order to access our service you will need to either be a resident, or be registered with a GP, in the London Borough of Hammersmith & Fulham. If you are unsure which IAPT service covers your area, please either use this link: www.nhs.uk/service-search/mental-health/find-an-nhs-talking-therapies-service or arrange to speak to your GP.

In response to the COVID-19 pandemic, if you work for the NHS or in a care setting in North West London* you will be eligible for priority access to support. To access this, please complete the below referral form. For further information, visit www.keepingwellnwl.nhs.uk

*Hammersmith & Fulham, Hounslow, Ealing, Harrow, Brent, Kensington & Chelsea, Westminster, Hillingdon.

Back on Track is not an emergency service and this referral form should not be used if you require urgent support. If you are worried about immediate risk of harm to self or others, please contact the following services 24 hours a day, 7 days a week: West London NHS Trust Helpline (0800 328 4444) NHS Helpline (111), and the Samaritans (116 123).

In taking your details, we recognise the importance of personal privacy and make sure all information about you is held securely in accordance with the General Data Protection Regulation (GDPR). We use data anonymously for monitoring purposes, however no one will be able to link any information back to you.

Everything you tell us is kept confidential, however if you disclose information concerning current or potential harm or risk to yourself or another, we may need to tell another party including your GP, the Police or Ambulance Service.

If you need support completing this form, please contact us on 0300 123 1156 or email wlm-tr.backontrack@nhs.net

* indicates required field

Please indicate whether this is a:*

Referral for yourself

Referral from a Health Care Professional

If Referral from a Health Care professional is selected, please complete the below details

Referrer name:

Referrer department:

Referrer telephone number:

Referrer email:

Title:*

First Name:*

Last Name:*

Date of Birth:*

Gender:*

Address Line 1:*

Address Line 2:

Town/City:*

Postcode:*

Email:*

Please note: We use your email address to confirm appointments only. If you do not have an email address, please input the following: noemail@nhs.net

Mobile Number:

Is it OK to leave a voicemail on your mobile number?

Yes

No

Is it OK to send a text to your mobile number?

Yes

No

Other Telephone Number (EG: work, home):

Is it OK to leave a voicemail on your other number?

Yes

No

Your GP has a key role in coordinating all the care you receive and so it is helpful to keep them up to date about whether you are accessing our service and other support you may need.

GP Name:

GP Surgery Name:*

Permission to Contact GP?*

Yes

No

Please be aware that at times we may need to contact your GP without your consent. This is usually if we are concerned about your safety or the safety of someone else.

Please see the section on our webpage titled ‘Problems we treat' (www.westlondon.nhs.uk/our-services/adult/iapt/IAPT-Hammersmith_Fulham-back-track-iapt/problems-we-treat) for information about the areas that we can and cannot help with. Please make sure to open this in a separate tab so that you don’t lose the information you have already provided.

Why do you want to refer yourself to Back on Track?*

Please specify or use this space to provide a brief description of your problem:

Please note if you have been signposted to our workshops via a community organization, it is really important to provide the code they gave you so that we can support you in accessing this promptly. Further support can be discussed following this workshop.

Are you currently being seen by any other service for mental health problems?*

Yes

No

If you answered yes, please give details:

Have you in the past ever been seen by any other service for mental health problems?*

Yes

No

If you answered yes, please give details:

Where did you hear about us?*

Other – please state:

What is your Nationality?*

What is your preferred language?*

Do you speak English?*

Yes

No

Are you able to understand written English?*

Yes

No

Do you need a translator?*

Yes

No

If yes, what language would you like during your appointments?*

Do you require any additional support in accessing our service?

If Other, please state:

Are you a carer for someone?*

Yes

No

Do you have a carer?*

Yes

No

If yes: Would you like your carer to be involved in your treatment?

Yes

No

If yes, please provide the details of your carer below:

Name:

Relationship to patient:

Contact Telephone number:

Address:

Are we able to speak to your carer about this self referral (e.g. if we are unable to contact you):

Yes

No

What is your ethnicity?*

What is your religion?*

What is your sexual orientation?*

Do you have a disability or long-term health condition?*

Yes

No

If yes, what is it?

If other, please specify:

Do you have any of the following medically unexplained symptoms?*

If other, please specify:

Are you an ex-member of the British Armed Forces?

In order to make our service accessible to your needs, please let us know if you are:

Currently expecting or adopting a baby

Have a child under 12 months old

If we think we are able to help you we will offer you an assessment appointment with one of our team. If we think that you could benefit from a different service we will contact you to let you know. If we decide that we are not the right service to offer you therapy, we may send your referral to another service that may be more appropriate for you within our Trust.

If you have questions about how we manage your information, you are welcome to discuss these with any staff member involved in your care.

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

Yes

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Self Referral Form

Referral

Your Details

GP Details

Referral Information

Further Information

What will happen next