Referral Form

NHS Talking Therapies ( Isle of Wight ) is for residents aged sixteen and over, who are registered with an Island GP Practice.

If you need urgent help, please contact our crisis number on 01983 522214. Please be aware our crisis number is only available 7am-10pm. Outside these hours, please contact NHS 111.

Do you feel you are at immediate risk of hurting yourself or attempting to end your life and need urgent help?*

No

If the answer is Yes, we’re sorry we are unable to accept a referral from you at the moment.

Please contact our crisis number on 01983 522214. Please be aware our crisis number is only available 7am-10pm. Outside these hours, please contact NHS 111.

Are you aged sixteen or over?*

Yes

If the answer is No, we’re sorry we are unable to accept a referral from you at the moment. Please contact your GP to discuss local services for children and young people.

Are you currently living in the Isle of Wight, and registered with a GP in the Isle of Wight?*

Yes

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

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

No

If the answer is Yes, we’re sorry we are unable to accept a referral from you at the moment. If you need clarification, please contact us on 01983 532860.

What is the main priority?*

Do you have a physical health condition?*

Yes

No

If yes, please specify:

If other, please specify:

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

Yes

No

Title:*

First Name:*

Last Name:*

At birth were you described as…:*

Male

Female

Intersex

Prefer not to say

Which of the following describes how you think of yourself now?:*

Male

Female

Not specified

Not known

What are your preferred pronouns?:*

If other, please specify:

Date of Birth:*

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

We’d like to keep you updated about your care at every step.

Please complete at least one contact number.

Mobile Phone Number:*

May we leave you a voice message?*

Yes

No

Can we send you an automated text message to confirm your appointment?*

Yes

No

Home Phone Number:

May we leave you a voice message?

Yes

No

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

Yes

No

May we email you about your care, containing personal identifiable information?*

Yes

No

May we email you 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 you.

First Name:*

Last Name:*

Phone Number:*

What is your relationship to this person?*

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

What is your ethnic group?*

What is your religion?*

What is your sexual orientation?*

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

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

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

Are you an ex-British Armed Forces Veteran?*

Are you 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, or do you have a baby under the age of 24 months?*

Yes

No

Do you require access to a ground floor consulting room?*

Yes

No

Do you have any additional needs we need to know about?

Do you have a disability which we need to be aware of?* E.g. Hearing, sight loss, use of wheelchair.

Yes

No

What is your first language?*

Can you speak and understand English?*

Yes

No

Would you like someone to provide sign language?*

Yes

No

If yes, please specify:

British Sign Language

Makaton

Would you like a language interpreter?*

Yes

No

If yes, please specify which language:

Do you require easy read material?*

Yes

No

Would you prefer to read things in large print?*

Yes

No

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

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 Isle of Wight 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.

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 - please contact us on 01983 532860.

I have read, understood, and agree to the data policy:*

Yes

If your answer is No, please contact us on 01983 532860.

Would you like to opt in or opt out of data sharing of your anonymised patient data for clinical research purposes?*

Opt in

Opt out

If you would like to contact NHS Talking Therapies ( Isle of Wight ) to discuss above - the telephone number is 01983 532860.

Where did you hear about NHS Talking Therapies (Isle of Wight)?*

If Other, please specify:

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

Please complete the captcha

Self Referral Form

May we first check…

How may we help you?

Tell us about you

How may we contact you?

Emergency contact

Additional details

Your GP practice

How else could we help?

Data policy

The final bit...

Review your information