Referral Form

The Staff Wellbeing Service provides support and talking therapies to staff working for Lincolnshire Partnership Foundation Trust.

Please note that the Staff Wellbeing Service is for mild to moderate mental health problems and cannot provide an urgent/emergency service, but we can support you to access the right service to support your needs. However if you feel you are at immediate risk of harming yourself, or someone else please contact your GP or call 999 as a matter of urgency. You can also call NHS 111 for advice or the Mental Health Matters Helpline 24 hours a day for emotional support on 0800 001 4331

Title:*

First Name:*

Last Name:*

Date of Birth:*

Gender:*

Male

Female

Not known

Not specified

Marital Status:*

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Permission to send written communication via post?:*

Yes

No

Phone Number:

Phone Type:

Permission to leave voicemail?:

Yes

No

Permission to send SMS text?:

Yes

No

Email Address:*

Permission to send email:*

Yes

No

GP Name:

GP Surgery Name:*

GP Surgery Address:*

Permission to share information with GP:*

Yes

No

Ethnicity:*

Religious or Belief affiliation:*

Ex-British Armed Forces:*

Sexuality:*

Do you identify as the same gender you were assigned at birth?:*

Long Terms Medical Conditions:*

If other, please state:

Does this condition have an impact on your emotional wellbeing?:

Yes

No

Disability:*

Please give brief details of why you wish to access the Staff Wellbeing Service. Can you describe the way that your problem impacts on your life, how long for have been experiencing this problem and any other information you feel we need to know?

Please give brief details of why you wish to access the Staff Wellbeing Service:*

Are you currently at work?:*

Yes

No

If you are currently absent or struggling to maintain work because of how you feel can you give brief details:

Are you employed by LPFT?:*

Yes

No

How did you hear about our service?:

Please complete the captcha

Self Referral Form

Personal Details

GP Details

Further Information

Referral Information