Referral Form

Thank you for registering your interest in one of our Back on Track workshops.

Back on Track is an NHS service offering mental health and wellbeing support for members of the Hammersmith & Fulham community.

By taking a few minutes to complete this form you are registering your details for a one-off workshop event. Our workshops are designed to help you think about your wellbeing and are facilitated by NHS Practitioners.

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 during your contact with our service that makes us concerned about your safety we may need to tell another party such as your GP to support you.

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

Yes

* indicates required field

Please provide the following details to register. We will then get in touch with you via email to provide you with information on how to access the workshop.

Title:*

First Name:*

Last Name:*

Date of Birth:*

Gender:*

Male

Female

Not known

Not specified

Address Line 1:*

Address Line 2:

Town/City:*

Postcode:*

Email Address:*

Mobile Phone Number:

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

Yes

No

Is it OK to sent text to your mobile number?:

Yes

No

GP Surgery Name & Address:*

Workshop code:*

*This will have been provided to you by the organisation that recommended our workshops. If you don’t know the code, please add the name of the organisation that you heard about us from.

What is your Nationality?:*

What is your ethnicity?:*

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

Yes

No

If yes, what is it?:

Other:

We ask everybody that uses our services to complete the questionnaires below – one asks about common symptoms of depression and one asks about common symptoms of anxiety. We use the symptom questionnaires to get an idea of how many people in the local population are experiencing anxiety and depression. This might not be relevant to you but it might be a prompt to think about how you have been feeling recently and whether it might be helpful to access some more support after the workshop.

Depression

Over the last 2 weeks, how often have you been bothered by any of the following problems?

1. Little interest or pleasure in doing things*

2. Feeling down, depressed, or hopeless*

3. Trouble falling or staying asleep, or sleeping too much*

4. Feeling tired or having little energy*

5. Poor appetite or overeating*

6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down*

7. Trouble concentrating on things, such as reading the newspaper or watching television*

8. Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual*

9. Thoughts that you would be better off dead or of hurting yourself in some way*

In the last 2 weeks, have you made plans to end your life?*

Yes

No

Please note: The answers to these questions may not be checked until the day of the workshop you have put yourself forward for as Back on Track is not an emergency service. If you are worried about immediate risk of harm to self or others, please speak to your GP. Alternatively, you can also contact the following services 24 hours a day, 7 days a week: West London Health Trust Helpline (0800 328 4444) NHS Helpline (111), and the Samaritans (116 123)

Anxiety

Over the last 2 weeks, how often have you been bothered by any of the following problems?

1. Feeling nervous, anxious or on edge*

2. Not being able to stop or control worrying*

3. Worrying too much about different things*

4. Trouble relaxing*

5. Being so restless that it is hard to sit still*

6. Becoming easily annoyed or irritable*

7. Feeling afraid as if something awful might happen*

We will be in touch with you via email to provide you with the link for attending the virtual workshop you have registered for, as well as information about where you can get more support and some useful self-help materials.

If you have questions about how we manage your information, you are welcome to discuss these with the workshop facilitators.

Please note: 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 speak to your GP. Alternatively, you can also contact the following services 24 hours a day, 7 days a week: West London Health Trust Helpline (0800 328 4444) NHS Helpline (111), and the Samaritans (116 123)

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Workshop referral form

Registration details

Monitoring Information

Questionnaires

What will happen next