Referral Form

SignHealth is a Primary Care Service only

If your patient is self-harming or has suicidal thoughts, please refer to your relevant Mental Health Service or patient can contact SHOUT text DEAF to 85258 for free and immediate support. IMPORTANT (SignHealth Psychological Therapy Service is not a Crisis Service).

NHS Number:

Title:*

First Name:*

Last Name:*

Address Line 1:*

Address Line 2:

Town:*

County:*

Postcode:*

Date of Birth:*

Gender:*

Mobile/SMS Number:*

Email:

BSL User:

Communication Information:

Understand written English?:*

Yes

No

Not Sure

Online Therapy - have internet at home?:

Yes

No

Does the patient have a:

Laptop

PC

Tablet

What does the patient use for Video Calls:

FaceTime

Zoom

Something else please advise below

Something else, please state here:

Referrer Name:*

Referrer Contact Number:*

Referrer Email Address:*

Referrer Job Title and Organisation:*

Referrer Organisation Address:*

GP Name:

GP Practice Address:*

GP Practice Contact Number:

GP Practice Email:

Clinical Commissioning Group:

The Patient has given consent for SignHealth Psychological Therapy Service/their doctor to contact the local Clinical Commissioning Group to gain funding for BSL Therapy and that SignHealth can stored the patient’s referral information on their secure confidential system in accordance with the Data Protection Act 2018:*

Yes

No

Long Term Condition:

Ethnicity:

Religion:

Relationship Status:

Any Children and if yes, how many?:

Employment Status:

Next of Kin Name:

Next of Kin Address:

Next of Kin Contact Number:

Presenting Problem - What is the main problem?:*

Please tick any additional problems:

If your patient is self-harming or has suicidal thoughts, please refer to your relevant Mental Health Service or patient can contact SHOUT text DEAF to 85258 for free and immediate support. IMPORTANT (SignHealth Psychological Therapy Service is not a Crisis Service).

Details of any RISK issues including neglect, violence and vulnerability:

Previous history of counselling, psychological therapies or any other mental health services? If yes, please give details including dates and when discharged:

Currently involved with any other counselling, psychological therapy or mental health services? If yes, please give details:

Medication? If so, please give details:

How did you find out about SignHealth Psychology Therapy Service?:*

If other, please specify:

We will be in touch with the patient within the next 7 days.

Please complete the captcha

Professional Referral Form for Deaf People

Patient Details

Referrer Information

Registered GP Details

Further Information

Next of Kin

Referral Information