Referral Form

V2

Welcome to Brent Talking Therapies Service. Please note that in order to access our service you will need to be registered with a GP in the London Borough of Brent.

If you are unsure which talking therapies service (IAPT) covers your area, please either use this link https://www.nhs.uk/Service-Search/Psychological therapies (IAPT)/LocationSearch/10008 or arrange to speak to your GP.

This self-referral form is a way for you to access psychological support and advice from your local talking therapies service. This service is for people who are experiencing stress, worry or low mood or struggling to cope with everyday life due to emotional difficulties. If you have a history of serious mental health issues or drug and alcohol problems it is possible we are not the best service 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, your local Accident & Emergency Department, or call the Urgent Advice Line on 0800 0234 650 open 24 hours.

By 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 Brent Talking Therapies Service on 020 8206 3924 or email cnw-tr.brent.iapt@nhs.net (Monday - Friday; 9am – 5pm)

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 *

Ethnicity

Are you able to have your appointments in English? *

Yes

No

If you have selected No, please specify the language (including BSL), and we will organise an assessment with an interpreter (please note that we use professional interpreters and will not use family members/friends to interpret for you).

Please select language:

Address Line 1 *

Address Line 2

Town/City *

County *

Postcode *

Home Number

Can we leave a voicemail?

Yes

No

Mobile Number

Can we leave a voicemail?

Yes

No

Can we send you text message reminders?

Yes

No

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.

Email *

Can we correspond with you via email? *

Yes

No

Please provide us with the name and contact number of someone you would like to put down in case of any emergency.

Name

Contact Number

Relationship to you

GP Name

GP Surgery Name *

GP Surgery Address *

We ask these questions to ensure that our service is being accessed by everyone and to ensure any specific requirements are met.

Sexuality

Disability

If Other, please specify

Are you an NHS or social care front line worker?

Yes

No

Are you, or your partner, pregnant or do you have any children under 1 or under 2?

Please describe the problem you need help with: *

Have you ever received treatment for these difficulties? *

Yes

No

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

What type of help are you looking for? *

Do you have any long-term medical conditions? *

If Other, please specify

Is there anything you would like us to know? *

Where did you hear about us? *

If other, please specify

We work in partnership with digital therapy services. To help reduce the wait for our service, your referral may be passed to one of our partner organisations who are Xyla Digital Therapies and Helloself. For further information on how we manage your personal information, please see https://www.cnwl.nhs.uk/patients-and-carers/your-information and https://talkingtherapies.cnwl.nhs.uk/faqs

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Brent Talking Therapies Service Self-Referral Form

Emergency Contact Details

GP Details

Further Information

Referral Information