Referral Form

v2

IAPT is not a crisis service.

It’s not uncommon for people struggling with their mental health to experience thoughts of being better off dead or of hurting themselves or others. However, if you have any specific plans or intent to harm yourself or others then our workshops would be not the most appropriate form of support for you at this time. In this instance you would be advised to seek more immediate support from one of the below services.

Please tick this box to confirm you have read and understood the above message before completing the below form:*

Yes

If you need urgent support, please do not complete this form. Instead, please:

- Call the SLAM 24-hour mental health helpline on 0800 731 2864

- Call the Samaritans on 116 123

Please complete all questions below - Your referral may not be processed until all the necessary information has been received.

Title:*

First Name:*

Surname:*

Date of Birth:*

Gender:*

Male

Female

Non binary

Unwilling to divulge

Address Line 1:*

Address Line 2:

Postcode:*

Landline Number:

Mobile Number:*

Email:*

Please write your email address again:*

GP Name and Practice:*

NHS Number:

What is your ethnicity?*

What is your religion?*

What is your sexual orientation?*

Are you a Goldsmiths University student?

Yes

No

Are you pregnant / have a child below 1?:*

Yes

No

Do you work for the NHS? (e.g. working in an NHS Trust, primary care, a charity funded by primary care, CCG etc.):*

Yes

No

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

Yes

No

If yes, what Borough do you work in?:

Have you had medical treatment because you had Covid-19?:*

Yes

No

Interpreter Required?:*

Yes

No

If yes, what language?:

Next of kin name:*

Next of kin relationship to you:*

Next of kin phone number:*

Special needs or adjustments: (for example, you are a wheelchair user)

Please select the workshop you would like to refer yourself to:*

Let’s Talk Men’s Wellbeing Workshop – Tuesday

Way Forward to Wellbeing Workshop – Monday

Way Forward to Wellbeing Workshop – Thursday

Stress & Worry Workshop – Single Session on Various Days

We use your phone number to call and text you about appointment information. We use your email address to contact you about your referral and also to seek feedback while you are engaging with our service or shortly afterwards. Therapists may also use your email address to contact you about appointments and send you resources. Please make sure you have written it accurately on the first page of this form.

People have told us that emails from us sometimes go into their spam folders. Please check these folders in your email account to ensure that you haven’t missed correspondence from us.

Information you share with us is confidential between you, our service and your GP. The only time we will break this confidentiality is if we are concerned that there is a serious risk of harm to you or someone else. We store information on our IT system. This is confidential, and cannot be accessed by anyone outside of our service. We do share anonymous information with NHS England and other statutory bodies that monitor our performance. This information may include details on the number of people we see, what type of treatment they receive, or if they recovered. This does not include your name, address, contact details etc.

Please confirm you understand and agree to the above:*

Yes

Are you okay with us sharing routine details with your GP to improve your care?*

Yes

No

Our service is part of King’s Health Partners who aim to improve services by conducting research. Would you be willing to be contacted by a researcher for a non-obligation discussion about helping with our research?*

Yes

No

If we think your needs are better met by another service, we would normally share your information in order to make a referral. Are you happy with this?:*

Yes

No

Your details will be reviewed by one our team. We will then contact you by email or telephone about progressing your referral.

For all enquiries, please call 0203 228 1350

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IAPT Lewisham: Workshop form

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