Referral Form

* indicates required field

How did you hear about our service?

In the text fields below, please use only letters, numbers, hyphens, single quotes and spaces. Other characters may not be accepted.

Title*

First Name*

Please use your full name - please do not use shortened names/abbreviations

Last Name*

You can only refer yourself to us if you are 16 or over.

Date of Birth*

Gender*

Address Line 1*

Address Line 2

Town/City*

County

Postcode*

Home Number

Can we leave a voicemail?

Yes

No

Please enter a telephone number starting with 07 and containing no spaces

Mobile Number

Can we leave a voicemail?

Yes

No

Can we send you text messages?

Yes

No

E-mail

Can we contact you by email (specifically to send you a questionnaire about your symptoms prior to your first appointment)?

Yes

No

Do you give us permission to speak to another person (ie a relative or friend) regarding appointments and cancellations only?

Yes

No

If yes, please specify who:

Would you like to give us details of someone you would like us to contact in case of an emergency?*

Yes

No

If yes, please specify their name, contact number and relation to you:

Name of GP Surgery*

GP Name

Do you give us permission to send copies of letters to your GP?*

Yes

No

Please note that if we identify any risk to yourself or to anyone else we may need to contact your GP regardless as part of our duty of care to ensure the safety of our patients and the people around them.

Religious or Belief Affiliation*

Nationality*

Ethnicity*

Are you able to communicate in English?*

Yes

No

Language*

Do any of these apply?

Have you ever served in the armed forces?*

Relationship Status*

Sexuality*

Preferred Pronoun*

She/Her

He/Him

They/Them

I prefer to self describe below

Self described pronouns

Please give us information on any disabilities (physical or learning) and any long term medical conditions (eg. diabetes, heart disease, COPD) you have*

Why do you currently want help and how long have you been feeling like this? (please write a few lines, not just one word)

Please choose one issue from the dropdown that most fits your view of your current situation

If you have selected 'Distressing event', please describe the type of event

To help us ensure we offer you the most appropriate treatment we need to know:

a) About any previous or recent support you have had from a Community Mental Health Team (CMHT) or psychiatrist, or any other mental health worker: (please give as much detail as you can – eg. dates, result)

b) If you have met with a counsellor or psychological therapist previously? (dates, benefit)

Please describe your use of alcohol and any drug use or current medications (per day/week, previous history of use, medical care, dosage)

By completing this form you consent to us saving your information on our database:

I consent to my data being saved

By completing this form you consent to your anonymised data being sent to the Dept of Health:

I consent to anonymised data being sent to the Dept of Health

Upon receipt of your referral, you will be contacted by the service to arrange your initial telephone assessment appointment or we may discuss transferring your care with other services if we are not the appropriate service to meet your needs.

We are not a general mental health service and are not able to offer crisis management or general support to people. If, in the meantime you experience deterioration in your symptoms or are finding yourself struggling to cope, please make an appointment to see your G.P.

Please complete the captcha

Self Referral Form

Your Details

Emergency Contact

GP Details

Your Personal Information

Reasons for referring yourself