Referral Form

Is Steps2Wellbeing for me?

To refer yourself to Steps2Wellbeing please complete the form below.

We accept referrals from adults registered with a GP in Dorset and Southampton city. Please note this service is for adults aged OVER 18 ONLY.

We offer talking therapy for common mental health issues. So, if you are feeling down, worried or stressed we can help. Sometimes symptoms like the ones below can happen because of our mental health.

• Trouble concentrating

• Worrying and feeling stressed

• Feeling sick, dizzy, heart beating fast

• Changes in sleeping and eating

• Losing interest in things you enjoy

• Feeling bad about yourself

We also offer treatment for people whose mental health is affected by a long-term health condition like:

• Diabetes

• Stroke

• Chronic pain

• IBS

I need emergency help

We are not a crisis service and are not the best service for you if you are very distressed, despairing, or suicidal.

If you need urgent help visit this website: https://www.steps2wellbeing.co.uk/help_me_now/

I don’t want anyone to know

We take confidentiality very seriously. The form is fully secure and all details you provide will be stored on our confidential system.

To get in touch with you and provide our services, we need to contact you. By completing this form, you agree to these terms and to be contacted via any available method.

We have a duty to share information with your GP and sometimes other healthcare providers to make sure that you are cared for. Further details can be found in our Treatment and Confidentiality Agreement. By completing this form, you are agreeing to the information and terms set out in the Treatment and Confidentiality Agreement. If you would like more information, you can talk to your Steps2Wellbring therapist about it.

You can read our Treatment and confidentiality agreement here - https://www.steps2wellbeing.co.uk/treatment_and_confidentiality_agreement/

Please note, fields marked with an asterisk * must be completed.

If you have not heard from Steps2Wellbeing within three working days of making a referral, please call us on 0800 484 0500 (Dorset) or 02380 272000 (Southampton).

Title:*

First Name:*

Last Name:*

Date of Birth:*

Gender:*

Male

Female

Other

Not known

Are you or your partner expecting a child?:*

Yes

No

Do you have a child/Children under the age of 24months?:*

Yes

No

House Name/No:*

Address:*

Town/City:*

County:*

Postcode:*

Email:

GP Surgery:*

GP Surgery Address:

Mobile Number:

Can a voicemail be left on this number?:

Yes

No

Can an SMS be sent to this number?:

Yes

No

Landline number (if you do not wish to provide a landline number please enter 0000000000):*

Can a voicemail be left on this number?:

Yes

No

Note: Please complete at least one contact number

Relationship Status:*

Sexual Orientation:*

Religion:*

Are you ex-British Armed forces?:*

Nationality:*

Ethnicity:*

Accommodation type:

Do you suffer from any long-term health conditions?:*

Please list long term conditions not ticked above:

Does your long term health condition impact on your mental health or vice versa?:*

Yes

No

Disabilities:*

Please give details of any accessibility requirements e.g. easy-read or large print information:

Are you currently a mental health inpatient, under the care of a community mental health team, or receiving psychological therapy from elsewhere?:*

Yes

No

Could you give us an outline of the main problem that you are having difficulty with / the reason you have referred?:*

How often do you drink alcohol?:*

How many drinks do you have when you are drinking? Please specify the alcohol type in the 'Details' box:*

Details:

Do you take any of the following drugs?:*

How often do you take drugs?:

Smoking: Are you a:

Would you like help to stop smoking?:

Yes

No

Are you currently involved with any other mental health services? Select all that apply:*

Please specify:

What is your employment status?:*

Are you currently attending work as normal?:*

If you are employed, how many hours do you work in a typical week?:

Are you currently receiving sick pay?:*

Are you currently receiving any of the following benefits?:*

Would you like support with any employment-related difficulties you may be having?:*

Please complete the captcha

Self referral form

Is Steps2Wellbeing for me?

Your Details

Further Details

Background Information