Referral Form

In order to be eligible for our service, you must be registered with a Brent GP (regardless of whether you live in Brent or not). In order to find out if you are registered with a Brent GP, please use this link https://beta.nhs.uk/find-a-psychological-therapies-service/ and then enter your GP practice details. The link will confirm if Brent Talking Therapies is the right service for you, or if you need to self refer to another IAPT service.

This self-referral form is a way for you to access psychological support and advice from your local talking therapies service. The service is for people who are having emotional difficulties and are struggling to cope with everyday life. If you have a history of serious mental health issues or drug and alcohol problems it is possible we’re not best suited to help you and we suggest you go to your GP for advice.

We are not able to provide immediate support in an emergency. If you require immediate help please contact your GP, or your local Accident & Emergency Department, or call the Urgent Advice Line on 0800 0234 650 open 24 hours.

Through completing this form you are consenting to have this information stored confidentially on a secure electronic system separate from your GP’s system, and for your GP to be informed of your contact with us.

If you are unable to complete this form for any reason or if you would prefer to give these details over the phone please call or email your local service.

By providing these details you are giving us consent to contact to you regarding confidential information.

Title

First Name

Last Name

Date of Birth

Gender

Male

Female

Not specified

Address Line 1

Address Line 2

Town/City

County

Postcode

Home Number

Can we leave a voicemail?

Yes

Mobile Number

Can we leave a voicemail?

Yes

Can we send you text message reminders?

Yes

Please note that, whilst NHS email is secure, we cannot guarantee that your own email server will be so. Please only give us your email if you are happy for confidential information to be sent to your email address.

Can we correspond with you via email?

Yes

GP Name

GP Surgery Name

GP Surgery Address

Please describe the problem you need help with:

Have you ever received treatment for these difficulties?

Yes

Please describe any treatment or support you’ve had for these difficulties:

What type of help are you looking for?

Would you like help getting a job or returning back to work (if signed off sick from work)?

Yes

Do you have a long term medical condition? E.g. cancer, stroke, diabetes.

If yes, please describe:

Is there anything you would like us to know?

How did you hear about us?

Please complete the captcha

Self Referral Form for Brent

GP Details

Referral Information