Self Referral Form

Register for NHS Hull – Your local NHS Talking Therapies

• NHS Hull Talking Therapies is available to those who have a registered Hull GP only.
• If you do not have a Hull GP visit www.nhs.uk/mental-health to find your local talking therapy service.
• If you are a health professional wanting to transfer care, this is not the correct process. You will need to email the service as per your agreed service referral route.

I agree to being assessed by the information I have provided on this form and this may be done without further contact. I am aware I may not speak to a therapist until the start of my identified treatment.
If no, please do not complete the below form and contact the service booking team on 01482 247111 to book an assessment with one of our assessors.
Once you have submitted your form one of our team will review the information you have provided and recommend a treatment where appropriate.
Where one to one talking therapy is recommended we may suggest that you attend a Introduction to CBT Course first. This allows us to provide you with information which can be helpful to everyone when managing symptoms of anxiety and depression. One to one therapy time can then build on this focusing on your individual needs.
Please copy the link for more information on our Introduction to CBT Course https://www.letstalkhull.co.uk/pages/introduction-to-cognitive-behavioural-therapy-cbt-course
If we need any further information from you to complete your registration with NHS Hull Talking Therapies, we will contact you within 28 days.
Alternatively if you are supporting someone to complete this form please ensure they provide as much information as possible.

Personal Details (Person requiring service only)

They are sent and received securely.

GP Details

Referral Information

There are no right or wrong answers, please be as honest as possible.
If you are wanting to make a referral for Couples Therapy please call us direct on 01482 247111 to arrange a separate assessment appointment, please do not complete this referral form. Couple Therapy for Depression is a behaviourally-based, 20-session couple therapy designed to treat depression in couples where there is also relationship distress. You may want to look at this link (https://tavistockrelationships.ac.uk/couple-therapy-for-depression) before attending your assessment as it will explain the difference between counselling for depression and marriage guidance.
The following questions are a first step in helping us to identify the best treatment for your problem. In answering each question please remember, there are no right or wrong answers.

Assessment Questionnaires

Please answer every question in the below questionnaires - this should take about 5 minutes to complete and are an essential part of your assessment for treatment. The questionnaires will help us identify symptoms of low mood and/or anxiety.

Low Mood and Depression

If you answered yes to Nearly Every Day, please call Mental Health Advice and Support on 0800 138 0990
PHQ-9 is adapted from PRIME MD TODAY, developed by Drs Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer Inc. For research information, contact Dr Spitzer at rls8@columbia.edu. Use of the PHQ-9 may only be made in accordance with the Terms of Use available at http://www.pfizer.com. Copyright 1999 Pfizer Inc. All rights reserved. PRIME MD TODAY is a trademark of Pfizer Inc.

If you answered either More Than Half the Days or Nearly Every Day to Question 9 above, please complete the following questions
If you answered yes to a current plan or current intent to take your life, please call Mental Health Advise and Support on 0800 138 0990 or contact the Samaritans on 116 123.
If selected Yes, please consider accessing support with ReNew on 01482 620013.

Anxiety

Over the last 2 weeks, how often have you been bothered by any of the following problems?*
MThe GAD-7 originates from Spitzer RL, Kroenke K, Williams JB, et al; A brief measure for assessing generalized anxiety disorder: the GAD-7. Arch Intern Med. 2006 May 22;166(10):1092-7. GAD-7 © Pfizer Inc. all rights reserved; used with permission.

Work & Social Adjustment

People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems look at each section and determine on the scale provided how much your problem impairs your ability to carry out the activity.
Ref: Mundt, J. C., I. M. Marks, et al. (2002). "The Work and Social Adjustment Scale: a simple measure of impairment in functioning." Br J Psychiatry 180: 461-4.

Phobia Scales

Choose a number from the scale below to show how much you would avoid each of the situations or objects.
The IAPT Phobia Scale is reproduced from the IAPT Toolkit which is ©Crown copyright. Reproduced under the terms of the Open Government Licence which can be found at http://www.nationalarchives.gov.uk/doc/open-government-licence/version/1/open-government-licence.htm

Further Information

Use of Information

By submitting this online referral form, you are agreeing to share your data with the NHS. For more information on how we collect, store and use your data - please see www.chcpcic.org.uk/pages/your-information-and-how-we-use-it.