Referral Form

Refer someone

Talking Therapies is for everyone aged sixteen or over, who live in Portsmouth and are registered with a GP in the city.

If you are a health or social care professional wishing to make an online referral on behalf of someone, you can use this secure form. The form takes up to 10 minutes to complete.

If you would like to refer yourself, please use the self-referral form.

Has the person you’re referring given you consent to make the referral?:*

Yes

No

If you selected No, we’re sorry we are unable to accept a referral for them at the moment. If they later decide to give their consent, you are welcome to refer them to Talking Therapies.

Has the person you're referring given consent to share information with the referrer?:*

Yes

No

Are they in crisis, feel they may seriously harm themself, or need immediate help?:*

Yes

No

If you selected Yes, we’re sorry we are unable to accept a referral for them at the moment. Please visit the ‘Urgent help’ section of our website for guidance.

Are they aged sixteen or over?:*

Yes

No

If you selected No, we’re sorry we are unable to accept a referral for them at the moment. Please ask them to contact their GP to discuss local services for children and young people.

Are they currently living in Portsmouth, and registered with a GP in the city?:*

Yes

No

If you selected No, we’re sorry we are unable to accept a referral for them at the moment. Please visit the ‘Refer’ section of our website for help finding their local service.

Are they currently receiving, or about to receive, therapy or mental health care from a different service?:*

Yes

No

If you selected Yes, we’re sorry we are unable to accept a referral for them at the moment. If you need clarification, please contact us on 0300 123 3934.

What is your full name?:*

What is your job title?*

Which service or organisation do you work for?*

What is your contact number?*

Do they have a physical health condition?:*

Yes

No

If Yes, please specify:

If Other, please specify:

Alongside therapy we can also assist them finding employment or training, and help them with workplace adjustments or disputes. Would they like support?:*

Yes

No

Brief description of the work already completed with client [if appropriate]:

Title:*

First name:*

Last name:*

At birth they were described as…:*

Male

Female

Intersex

Prefer not to say

Which of the following describes how they think of themselves now?:*

Male

Female

In another way

Prefer not to say

If in another way, please specify:

Date of Birth:*

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

We’d like to keep them updated about their care at every step.

Mobile phone number:

May we leave them a voice message?:

Yes

No

May we send them a text message?:

Yes

No

Home phone number:

May we leave them a voice message?:

Yes

No

We will ask them to complete questionnaires before each appointment to help us understand how they’re feeling. They may prefer to complete them online to save time. May we email them with a secure link?:*

Yes

No

May we send them an email about their care, containing personal identifiable information?:*

Yes

No

May we email them with therapy materials?:*

Yes

No

Email address:

The NHS uses an encryption feature for all emails to correspond securely.

In the event of an emergency, please provide the details of someone who we can contact – ideally someone who lives nearby them.

First name:

Last name:

Phone number:

We ask these next questions to make sure we’re doing our best by reaching out to everyone in the community.

What is their ethnic group?:*

What is their religion?:*

What is their sexual orientation?:*

We keep them informed about their appointments and care, and copies of these communications are sent to their GP to keep them updated.

Please select the name of the GP practice where they’re registered:*

We support people with a wide range of needs, and we want to be as helpful as possible.

Are they an ex-British Armed Forces Veteran?:*

Are they related to a serving member or a veteran of the British Armed Forces?:

Yes - Currently serving member

Yes - Veteran

No

Are you or your partner pregnant?:*

Yes

No

Do you have a baby under the age of 24 months?:*

Yes

No

Would they like someone to provide sign language?:*

Yes

No

If Yes, please specify:

British Sign Language

Makaton

Would they like a language interpreter?:*

Yes

No

If Yes, please specify which language:

Do they require easy read material?:*

Yes

No

Would they prefer to read things in large print?:*

Yes

No

Would they prefer to receive online therapy?:*

Yes

No

Do they need help with weight management?:*

Yes

No

Do they need help with sleep?:*

Yes

No

Please ensure the text below is understood by the person you’re referring.

Talking Therapies and Solent NHS Trust safely manage and share the information collected about you, in compliance with the Data Protection Act (2018) and the General Data Protection Regulation (2016).

We keep the information that you share with us on a dedicated computer system to ensure that it is stored safely. Your information may also be accessed securely by other mental health services within Solent NHS Trust to plan and monitor your care. We may also want to share information with other professionals who need to be involved in your care, and in this event we will ask for your permission beforehand. We may need to share information with other professionals without your permission if we are concerned about your safety, the safety of another person, or you inform us that you have/or are about to commit a serious crime. Should this be the case we will discuss this with you first and involve you in the process if possible.

We will provide your GP with a copy of the letters that we send to you to keep your medical records updated, and we are required to send a limited amount of information relating to your care to NHS Digital who will remove your identifying details and use it to assist in the monitoring and the commissioning of mental health services in England.

We are proud to be an organisation that promotes and supports clinical research, whilst maintaining confidentiality. Our ‘Count Me In’ initiative means that if there is a research study or service improvement project we think you might be interested in, we will contact you to see if you would like to be involved. More information about the initiative can be found by visiting: www.academy.solent.nhs.uk/research/count-me-in

If you have any questions about this policy - if you do not wish for your information to be shared with your GP, other mental health services or NHS Digital, or if you wish to opt out of the ‘Count Me In’ initiative - please contact us on 0300 123 3934.

Do they understand and agree to the data policy?*

Please select:*

Yes

No

If you selected No, please contact us on 0300 123 3934 before submitting their referral.

We’d like to share our latest news with them by email – we provide updates about our therapies, our community projects, and our free wellbeing workshops across Portsmouth.

Would they like to receive our newsletter?:*

Yes

No

Please inform them that Talking Therapies uses Sendinblue to email our newsletters. Sendinblue will be responsible for storing and managing their name and email address. They can unsubscribe and remove their details at any time. The ‘Policies’ section of our website provides further information.

It’s important we understand how they heard about us to make sure that we’re doing our best reaching out to everyone in the community.

Where did they hear about Talking Therapies?:*

If other, please specify:

Carefully review their information before submitting the referral. When they’re ready, click on the ‘Submit’ button below. We’ll let you know that we’ve received their information securely.

Please complete the captcha

Self Referral Form

Refer someone

May we first check…

Tell us about you

How may we help them?

Tell us about them

How may we contact them?

Emergency contact

Additional details

Their GP practice

How else could we help?

Data policy

The final bit…

Review their information