Referral Form

All information kept securely in accordance with the Data Protection Act and General Data Protection Regulation (GDPR).

Time to Talk 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 and Crawley - 01403 620434

Mid Sussex - 01444 251084

South (Adur, Arun, Chanctonbury & Worthing) - 01903 703540

West (Chichester, Bognor & surrounding areas) - 01273 265967

Before going any further please answer the following 6 questions;

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, people can call on the phone numbers listed above or can be referred via their GP.

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 please make an appointment with your GP to discuss the available options.

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.

I agree that Time To Talk will share information with my GP or obtain information from them if needed*

Yes

If you would like more information about this please call in on the numbers given above.

I agree that Time to Talk 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 in on the numbers given above.

Will you be available for a 30-60 minute assessment in the next two weeks?*

Yes

If this is not the case please make contact again when you do have availability in the next fortnight.

If you answered “Yes” to all of the above please complete all fields on the form below to access the Time To Talk service. If not, please do not continue with this form as we will not, unfortunately, be able to accept your referral at this time.

After you submit this form our admin team will contact you by telephone within three working days to arrange an assessment with a therapist. This assessment will take 30-60 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.

Title:*

First Name:*

Surname:*

Gender:*

Male

Female

Not specified

Date of Birth:*

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Landline phone number (leave blank if not applicable):

Landline phone number type:

Can we leave messages on this number?

Yes

No

Mobile Number (leave blank if not applicable):

Can we leave messages on this number?

Yes

No

Can we send you SMS text reminders?

Yes

No

If you would like to be contacted via email (regarding appointments and questionnaires only), please provide your email address. Please note, although we can guarantee the appropriate security of our nhs email system, during transfer over the Internet we cannot guarantee the security of the email, or be responsible for the security of any emails once sent or in the patient’s own email inbox.

Email Address:

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 Time to Talk 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 Time to Talk Health Team who are part of our service and have additional knowledge of these conditions and their impact on wellbeing.

Time to Talk is not able to offer crisis/urgent support. If you need more immediate support please consider the following;

- Request an urgent appointment with your GP

- Attend your local A&E department

- Contact the West Sussex Mental Health Line on 0800 0309 500 (24 hours)

- Contact the Samaritans on 116 123 (24 hours)

For security purposes please look at the images below and type the words in the white box

Please complete the captcha

Time To Talk Online Self-Referral Form

Access Questions

Personal Details

Further Information

If you need urgent help or support in a crisis