Referral Form

NHS West Sussex Talking Therapies is not a crisis service and we are not able to provide crisis support. If you are in crisis and need urgent support, please do not fill this form in and instead contact one of the following services:

• Sussex Mental Healthline: 0800 0309 500 (24hrs)

• The Samaritans: 116 123 (24hrs)

• 111 and ask for crisis support

• Your local A&E department

• Stay Alive App

• Your GP, and request an urgent appointment

NHS West Sussex Talking Therapies is a friendly and approachable service offering a variety of talking therapies to adults struggling with anxiety or depression in West Sussex. This form allows you to refer yourself to the service. If you have any problems completing it - or have additional needs which would be helpful for us to know about - please phone our admin team on the relevant number below and they will continue with your referral over the telephone:

Horsham, Mid-Sussex and Crawley - 01403 620434

Adur, Arun, Chanctonbury & Worthing - 01903 703540

Chichester, Bognor & surrounding areas - 01273 265967

Are you completing this form for yourself? (i.e. not on behalf of someone else)*

Yes

You cannot fill in this form on behalf of someone else. This form is not, however, the only way to access the service. You can call on the phone numbers listed above or can be referred via your GP.

The following section collects your personal information. All information is kept securely in accordance with the Data Protection Act and General Data Protection Regulation (GDPR) and is shared only with healthcare professionals in relation to your treatment. For more about how we use your data please see our privacy policy: www.sussexcommunity.nhs.uk/services/time-talk-service/time-to-talk-and-time-to-talk-health-privacy-policy.htm

After you submit this form you will be contacted within three working days to arrange an assessment with a therapist. This assessment will take 45-60 minutes and will help us clarify your needs and determine whether this is the best service for you. PLEASE BE AWARE THAT WHEN WE CALL YOU OUR TELEPHONE NUMBER WILL SHOW AS “WITHHELD” ON YOUR PHONE.

Are you 18 or over?*

Yes

We are an adult service and do not treat people under 18 years old. If you are under 18 and wish to access talking therapy you can self-refer on the e-wellbeing website (e-wellbeing.co.uk/support) or make an appointment with your GP to discuss the available options.

Do you live in West Sussex?*

Yes

If this is not the case, you can find your local talking therapy service by visiting the NHS Choices website at www.nhs.uk. If you would prefer to be seen by us, please contact the phone number above to discuss your referral.

Are you registered with a GP practice in West Sussex?*

Yes

If this is not the case you can find your local talking therapy service by visiting the NHS Choices website at www.nhs.uk. If you would prefer (or still like) to be seen by us, please contact the phone number above to discuss your referral.

Will you be available for a 45-60 minute assessment in the next six weeks?*

Yes

We will aim to offer an assessment within a few weeks and ask that you are available for this within the next six weeks of making this referral. If you will be unavailable for assessment within the next six weeks, we would ask you to refer at a time when you are available. Please note we are not a crisis service.

I agree that NHS West Sussex Talking Therapies will share information with my GP or obtain information from them if needed*

Yes

If you would like more information on this, please call the relevant number above.

I agree that NHS West Sussex Talking Therapies may access my health records from secondary care mental health services e.g the ATS (Assessment and Treatment Service) or Specialist Perinatal Mental Health Service, where the sharing of information would support my best care.*

Yes

If you would like more information about this please call the relevant number above.

If you answered “Yes” to all of the above, please complete all fields on the form below to access the NHS West Sussex Talking Therapies service. If you’re unable to answer “Yes” to any of the above and would still like to access the service, please call us on the number above to discuss.

Title:*

First Name:*

Surname:*

What are your pronouns? (e.g. she/her, he/him, he/they etc.)

Are you pregnant or have a child under the age of 12 months?*

Yes

No

Date of Birth:*

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Mobile Number:*

We need a mobile number in order for you to self-refer online. If you cannot provide a mobile number we can still register you over the phone - please ring us using the contact details at the top of this form to self-refer. If you consent to us sending you text messages in the question below, we can send out a booking link so you can book your initial assessment online quickly. If you don't consent to us sending text messages, we will ring you to book in your initial assessment.

Can we send you SMS text reminders?*

Yes

No

Can we leave messages on this number?*

Yes

No

Email Address:*

Confirm Email Address:*

I consent to being sent emails about appointments and questionnaires:*

Yes

We need an email address in order for you to self-refer online. If you cannot provide an email address we can still register you over the phone - please ring us using the contact details at the top of this form to self-refer.

To find out about the way we send emails view our privacy policy www.sussexcommunity.nhs.uk/services/time-talk-service/time-to-talk-and-time-to-talk-health-privacy-policy.htm

Do you work for the NHS? (e.g. an NHS Trust, primary care, or a charity funded by primary care, CCG.)

Yes

No

Do you work in Social Care? (i.e. you work for the local authority, in a care home, or providing care for residents at home)

Yes

No

If you need a language interpreter for appointments (including British Sign Language) please indicate the language required:

Are you (or have you in the past) received help from another mental health or specialist service (e.g. drug/alcohol service)?* You do not need to answer Yes for any GP or NHS West Sussex Talking Therapies appointments.

Yes

No

If Yes, Please specify which service AND when you last had contact with them (approximately):

Please tick if you have been diagnosed with any of these conditions AND it is directly contributing to your stress levels or low mood:

If you ticked any of these conditions your referral may be passed to the long-term conditions team who are part of our service and have additional knowledge of these conditions and their impact on wellbeing.

Do you have any disabilities we need to know of?

Yes

No

Do you require any adjustments or have other difficulties that would affect communication with us?

Yes

No

If yes to any of the above, let us know how best to contact you and we will try our best to accommodate:

Equalities and monitoring

It is helpful if we know some further information about you for national reporting. It is not mandatory to answer the questions below. If you do not want to answer a question, please select ‘prefer not to say’ but if you do, this data will be anonymous and will not be viewed by anyone within our service. For more about how we process this date please see our privacy policy www.sussexcommunity.nhs.uk/services/time-talk-service/time-to-talk-and-time-to-talk-health-privacy-policy.htm

Gender:*

Is your gender the same as that assigned at birth?:

Ethnicity:*

Sexuality:*

Relationship Status:*

Religion:*

How did you hear about NHS West Sussex Talking Therapies?

I have read the privacy policy and understand how the service will use my data:*

Yes

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NHS West Sussex Talking Therapies

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Personal Details

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