Referral Form

* indicates a required field

Referrer name:*

Surgery/Service Name:*

Email Address:*

Contact Number:*

Date of referral:*

Title:*

First Name:*

Last Name:*

NHS Number:

Date of Birth:*

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Home contact number:

Mobile contact number:*

Permission to leave voicemail:*

Yes

No

Permission to contact by SMS:*

Yes

No

Email:

Gender:*

Is this the service user’s birth gender?:*

Yes

No

If NO how does the service user identify? What is the preferred pro-noun?:

Sexual Orientation:*

Ethnicity:*

Does the patient speak English?:*

Yes

No

Unknown

Is a translator necessary?:*

Yes

No

Does the patient have someone that they consent us speaking with who could help book the 1st appointment?

Name:

Contact number:

Is the patient pregnant/have they given birth in the last 12 months?:*

Yes

No

Has the patient ever served in the armed Forces?:*

Yes

No

If yes for the above is this:

Ex Military

Current Military

Is the patient an NHS worker, Care home Worker?:

Yes

No

Does your patient have a Long-Term Physical health condition?:*

If other, please state:

We support patients with difficulties in coming to terms with a long-term physical health condition and in learning to follow health advice. Are you referring someone for this type of support?:

Yes

No

To help us to support your patient to access the service, can you let us know if any of the following apply:

If other, please state:

Current medication (+dose):

If we feel that another Trust service is better placed to support your patient at this time we will refer them on directly. Please select this option if your patient DOES NOT want us to share their information in such circumstances:

No

Reason for referral (Please detail reasons for referral, including existing and historic mental health diagnoses, interventions already tried and response to these):

Please note that we rely on information about risk to judge the urgency of a referral. If it is incomplete it will be assumed that there is no risk.

Risks – e.g. suicide, self-harm, risk of self-neglect, risk to others, risk from others, protective factors.

Please note that IAPT is not an emergency service. In the case of an emergency, we request that patients contact their GP or visit their local A&E department. Patients can also access telephone support via Samaritans - 08457 90 90 90 (open 24 hours daily) or the Mental Health Support Line – 0800 028 8000 (5pm to 9am Mon-Fri, 24 hrs weekends & bank holidays).

In order to reduce waiting times and ensure timely assessment and treatment, we work closely in partnership with digital providers. These providers are currently Xyla digital therapies, IESO and Silver Cloud.

Does your patient/client consent to share their information and being contacted by these services if appropriate?*

Yes

No

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Wandsworth IAPT Professional Referral Form

Client Details

Referral Reason

Risk