Health Professional Online Referral Form

This online referral form is only to be used by health professionals, and specifically for referrals to the Let’s Talk therapy team – it is not for referrals to Primary Mental Health Nurses.

All fields need to be completed where indicated *.

Title*

First Name*

Last/Family Name*

Date of Birth*

Gender*

Male

Female

Other

NHS Number*

Address Line 1*

Address Line 2*

Town/City*

County*

Postcode*

Mobile Number

Text Messages to be left*

Yes

Voicemail to be left*

Yes

Landline Number

Voicemail to be left*

Yes

G.P. Surgery Name*

G.P. Name*

G.P. Surgery Address*

G.P. Contact Number*

Referrer Name*

Referrer Team & Address*

Contact Number*

Referral Reason (Identified problem)*

Is there any Risk to Self/others?*

Current Medication (including dose and duration)*

Language*

Able to communicate in English?*

Yes

Interpreter required?*

Yes

Seen by Mental Health services before? If yes, please give details*

Is your patient currently pregnant or has given birth in the last 2 years?

Yes

If yes, please give the estimated due date or child's date of birth.

Any further information relevant to referral?

Please complete the captcha

Health Professional Online Referral Form

Patient Details

GP Details

Referral Source

Referral Details

Patient’s Requirements/Needs

Other Details