Self Referral Form
Please note that in order to access our service you will need to be registered with a GP, or live, in the London Borough of Ealing. If you are unsure which NHS Talking Therapies 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.
If you work for the NHS or in a care setting in North West London (Hammersmith & Fulham, Hounslow, Ealing, Harrow, Brent, Kensington & Chelsea, Westminster, Hillingdon), you may also be eligible for our support via our priority service. For further information visit: www.keepingwellnwl.nhs.uk
Any information that you share with the Ealing NHS Talking Therapies service will be treated in strict confidence in accordance with the provisions of the Data Protection Act 1998 and GDPR
We collect demographic information, such as religion and sexual orientation to ensure equity of service
* indicates required field
This referral form should only be used to refer yourself. If you are a Health Care Professional wishing to make a referral for a client, please use our HCP form
PERSONAL DETAILS
Title:*
Please Select A Value...
Dr
Miss
Mr
Mrs
Ms
Mx
Prof
Rev
Your First Name:*
Your Last Name:*
Your Preferred Name:
Date of Birth:*
Gender:*
Female - Including Trans Woman
Male - Including Trans Man
Gender-Fluid
Gender-Queer
Non-Binary
Other
Prefer not to disclose
Not known
What are your preferred pronouns, if any?
Please Select A Value...
Ae/Aer/Aer
Ey/Em/Eir
Fae/Faer/Faer
He/Him/His
Per/Per/Pers
She/Her/Her
They/Them/Their
Ve/Ver/Vers
Xe/Xem/Xyr
Ze/Hir/Hir
Address Line 1:*
Address Line 2:
Town:*
County:*
Postcode:*
We will use your email address to confirm appointments and other communication relevant to your treatment.
If you do not have an email address or do not wish to provide one, please input the following: noemail@nhs.net
Email Address:*
I prefer to receive correspondence via:*
Email
Post
We will use your mobile number to confirm appointments, send you questionnaires relevant to your treatment, and patient experience questionnaires.
We use an online appointment booking system, which allows you to choose and book your appointment. You will be sent a booking link via SMS (NB if you opt out of SMS communication, this feature will not be available to you and we will contact you to book your appointment manually)
Mobile Number:*
Can we leave a voice message on this number?:*
Yes
No
Can we send you SMS Communication?:*
Yes
No
Would you like to nominate someone we can contact in case of emergency:
Yes
No
Your chosen person will only be contacted in an emergency and will be able to act on your behalf if you are unable to communicate with us.
If yes, please provide their contact details below.
What is their name:
What is your relationship to them?:
What is the best contact number for them?:
CARE AND SUPPORT INFORMATION
Do you consider yourself to have a disability?*
Yes
No
Do not wish to disclose
If 'Has Disability' selected, please select the nature of the disability from the list:
Please Select A Value...
Behaviour and Emotional
Hearing
Manual Dexterity
Memory or ability to concentrate, learn or understand (Learning Disability)
Mobility and Gross Motor
Perception of Physical Danger
Personal, Self Care and Continence
Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits etc)
Sight
Speech
Other
Do you consider yourself to have a long-term health condition?:
Yes
No
Do not wish to disclose
If you have answered yes, please specify the nature of your long-term health condition:
Arthritis
Asthma
Autoimmune Disease Disorder
COPD
Cancer
Cardiac arrest (heart attack)
Celiac Disease
Cerebral Palsy
Chronic Fatigue Syndrome
Chronic Kidney Disease
Chronic Muscular Skeletal
Chronic Pain
Dementia
Diabetes
Digestive Disorders
Eczema
Epilepsy
Fibromyalgia
Heart Disease
Heart Failure
Hepatitis B and hepatitis C
Human immunodeficiency virus (HIV) infection
Irritable Bowel Syndrome (IBS)
Liver Disease
Long Covid
Medically Unexplained Symptoms
Multiple Sclerosis
Parkinson's Disease
Respiratory disease (not COPD or asthma)
Stroke
Thyroid disorder
Transient ischemic attack (TIA or mini-stroke)
Other
Do you have any information or communication needs? For example, receiving correspondence in audio, braille, easy read or large print.
Yes
No
Do not wish to disclose
If you have answered yes, please provide the following information:
Communication Support:
Specific Contact Methods:
Specific Information Formats:
Communication Professional:
Does anyone (e.g. a family member, partner or friend) support you due to additional needs?)
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
Do you look after anyone (e.g. a family member, partner or friend) who would not be able to cope without your support due to additional needs?:
Yes
No
Are you pregnant or a parent of a child under the age of 1?:*
Yes
No
If you are pregnant, when is your due date?
If you a parent of a child who is under the age of 1, please provide their DoB:
DEMOGRAPHIC INFORMATION
What is your ethnicity?:*
Please Select A Value...
Asian or Asian British - Afghani
Asian or Asian British - Bangladeshi
Asian or Asian British - Indian
Asian or Asian British - Japanese
Asian or Asian British - Pakistani
Asian or Asian British - Sri-Lankan
Asian or Asian British - Filipino
Asian or Asian British - Vietnamese
Asian or Asian British - Any other Asian background
Black or Black British - African
Black or Black British - Caribbean
Black or Black British - Somalian
Black or Black British - Any other Black/African/Caribbean background
Mixed - White and Asian
Mixed - White and Black African
Mixed - White and Black Caribbean
Mixed - Any Other Mixed or Multiple Ethnic Background
White - Eastern European
White - English, Welsh, Scottish, Northern Irish or British
White - Gypsy or Irish Traveller
White - Irish
White - Roma
White - Any other White background
Other Ethnic Groups - Arab/Any other Middle Eastern background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Iranian
Other Ethnic Groups - Iraqi
Other Ethnic Groups - Polish
Other Ethnic Groups - South American
Other Ethnic Groups - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
What is your religion?:*
Please Select A Value...
Agnostic
Baha'i
Buddhist
Christian
Hindu
Jain
Jewish
Muslim
Pagan
Sikh
Zoroastrian
Any other religion
Not religious/ no religion
Patient does not wish to state
Patient Religion Unknown (Patient not asked)
What is your sexual orientation?:*
Please Select A Value...
Bisexual
Heterosexual
Lesbian or gay
Other
Unknown
Does not wish to state
Are you Ex-British Armed Forces?:*
Please Select A Value...
Yes - ex services
No
Dependant of a ex-serving member
Not stated (Person asked but declined to provide a response)
Unknown (Person asked and does not know or isn't sure)
Do you speak English?:*
Yes
No
If no, what is your preferred language?
Do you require a translator/interpreter for your appointments?
Yes
No
GP DETAILS
Please Confirm the Name of the GP Surgery you are registered with:*
Your NHS number (if known):
FURTHER INFORMATION
What is the main difficulty you would like support with?:*
Please Select A Value...
Low Mood/Depression
Worry/Anxiety
Stress
Panic
Specific Fears e.g. heights, social situations
Other
If other, please specify:
Are you currently receiving care from any service related to mental health (e.g. Single Point of Access, Crisis and Assessment Team, Liaison Psychiatry, Recovery Team, Early Intervention)?:*
Yes
No
Not sure
Where did you hear about our service?:*
Ealing NHS Talking Therapies is a 9am – 5pm service and unable to provide urgent support. If you require urgent/crisis support, or if you are worried about immediate risk of harm to self or others, please call the 24/7 West London Helpline on 0800 328 4444 or the Samaritans on 116 123.
Please tick to confirm you have understood this
Yes
If you currently have a diagnosis of psychosis, schizophrenia, or a personality disorder, please make an appointment with your GP who will be able to refer you to the most appropriate service. Similarly, if you have had a recent admission to a psychiatric unit, please speak to your GP or care coordinator.
Please tick to confirm you have understood this
Yes
If we decide that we are not the most appropriate service for you, we may send your details to another service that may be more appropriate.
Please tick to confirm you have understood this
Yes
If we have concerns about your safety, we have a duty of care to liaise with appropriate healthcare professionals (GP, care co-ordinator, Psychiatrist, Nurse, etc) to ensure that necessary support is arranged.
Please tick to confirm you have understood this
Yes
In order to reduce wait for the service, we now work in partnership with Xyla Digital Therapies and Dr Julian. These services offer timely assessments and treatments. Do you consent to being contacted by either of these services if appropriate?
Do you consent to being contacted by this service if appropriate?*
Yes
No
Please complete the captcha
Submit
Cancel
