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.
I agree:*
Yes
No
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 tick Yes or No if you would like to access our 4 week Introduction to CBT Course and complete the below information:
Yes
No
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)
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
First Name:*
Preferred Name:
Surname:*
Previous surname:
Date of Birth:*
Gender Identity:*
Male
Female
Transgender
Non-binary
Not Known
Not Stated
Is gender the same as that assigned at birth?:*
Yes
No
Not Stated
Not Known
Pronouns:
Address line one:*
Address line two:
Town:*
County:*
Postcode:*
Previous address:
If another person answers your phone can we leave a message with them?*
Yes
No
If yes, please give their name(s):
Home Number:
Mobile Number:
Can we leave voicemails?:
Yes
No
Can we send this number texts?:
Yes
No
Email:
Confirm Email:
As part of your treatment you will be completing questionnaires, do you consent to receiving these via email?
Yes
No
They are sent and received securely.
GP Details
Registered GP Surgery:*
GP Name (if known):
GP Surgery Address (if known):
Referral Information
Referral Date:* (DD-MM-YY)
There are no right or wrong answers, please be as honest as possible.
What are the current problems(s) that have led you to ask for help? (please give as much relevant information as possible):*
How long have you been experiencing these problems?:*
If you've identified a number of problems, which is having the biggest impact on you currently?:
Is your reason for referral due to a recent bereavement?:*
Yes
No
Is your reason for referral for couples counselling?:*
Yes
No
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.
Have you had previous treatment with any Mental Health Services?:*
Yes
No
If yes, please give further details:
Are you currently registered for care with a mental health service? Please indicate which one, if known:
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
1 Little interest or pleasure in doing things
Not At All
Several Days
More Than Half The Days
Nearly Every Day
2 Feeling down, depressed or hopeless
Not At All
Several Days
More Than Half The Days
Nearly Every Day
3 Trouble falling or staying asleep, or sleeping too much
Not At All
Several Days
More Than Half The Days
Nearly Every Day
4 Feeling tired or having little energy
Not At All
Several Days
More Than Half The Days
Nearly Every Day
5 Poor appetite or overeating
Not At All
Several Days
More Than Half The Days
Nearly Every Day
6 Feeling bad about yourself - or that you are a failure or have let yourself or your family down
Not At All
Several Days
More Than Half The Days
Nearly Every Day
7 Trouble concentrating on things, such as reading the newspaper or watching television
Not At All
Several Days
More Than Half The Days
Nearly Every Day
8 Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual
Not At All
Several Days
More Than Half The Days
Nearly Every Day
9 Thoughts that you would be better off dead or of hurting yourself in some way
Not At All
Several Days
More Than Half The Days
Nearly Every Day
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
Do you have any current intent to take your life at the moment?
Yes
No
Do you have any current or immediate plans to take your life?
Yes
No
Have you ever attempted to take your own life before?
Yes
No
Are you currently using deliberate self-harm to manage your emotions?
Yes
No
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.
Do you consider yourself to have a problem with the misuse of Drugs or Alcohol?:*
Yes
No
Don't know
If selected Yes, please consider accessing support with ReNew on 01482 620013.
Please provide additional information around your Drug or Alcohol misuse:
Anxiety
Over the last 2 weeks, how often have you been bothered by any of the following problems?*
1 Feeling nervous, anxious or on edge
Not At All
Several Days
More Than Half The Days
Nearly Every Day
2 Not being able to stop or control worrying
Not At All
Several Days
More Than Half The Days
Nearly Every Day
3 Worrying too much about different things
Not At All
Several Days
More Than Half The Days
Nearly Every Day
4 Trouble relaxing
Not At All
Several Days
More Than Half The Days
Nearly Every Day
5 Being so restless that it is hard to sit still
Not At All
Several Days
More Than Half The Days
Nearly Every Day
6 Becoming easily annoyed or irritable
Not At All
Several Days
More Than Half The Days
Nearly Every Day
7 Feeling afraid as if something awful might happen
Not At All
Several Days
More Than Half The Days
Nearly Every Day
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.
1 WORK - if you are retired or choose not to have a job for reasons unrelated to your problem, please select N/A (not applicable)
0 - Not At All
1
2 - Slightly
3
4 - Definitely
5
6 - Markedly
7
8 - Very severely
N/A
2 HOME MANAGEMENT - Cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc
0 - Not At All
1
2 - Slightly
3
4 - Definitely
5
6 - Markedly
7
8 - Very severely
3 SOCIAL LEISURE ACTIVITIES - With other people, e.g. parties, pubs, outings, entertaining etc
0 - Not At All
1
2 - Slightly
3
4 - Definitely
5
6 - Markedly
7
8 - Very severely
4 PRIVATE LEISURE ACTIVITIES - Done alone, e.g. reading, gardening, sewing, hobbies, walking etc
0 - Not At All
1
2 - Slightly
3
4 - Definitely
5
6 - Markedly
7
8 - Very severely
5 FAMILY AND RELATIONSHIPS - Form and maintain close relationships with others including the people that I live with
0 - Not At All
1
2 - Slightly
3
4 - Definitely
5
6 - Markedly
7
8 - Very severely
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.
1 Social situations due to a fear of being embarrassed or making a fool of myself
0 - Would not avoid it
1
2 - Slightly avoid it
3
4 - Definitely avoid it
5
6 - Markedly avoid it
7
8 - Always avoid it
2 Certain situations because of a fear of having a panic attack or other distressing symptoms (such as loss of bladder control, vomiting or dizziness)
0 - Would not avoid it
1
2 - Slightly avoid it
3
4 - Definitely avoid it
5
6 - Markedly avoid it
7
8 - Always avoid it
3 Certain situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in confined spaces, driving or flying)
0 - Would not avoid it
1
2 - Slightly avoid it
3
4 - Definitely avoid it
5
6 - Markedly avoid it
7
8 - Always avoid it
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
Please indicate your current employment status:*
Please Select A Value...
Employed full-time
Employed part-time
Unemployed and Seeking Work
Student (Not Working)
Retired
Full-time homemaker or carer
Self-employed full-time
Self-employed part-time
Long-term sick or disabled, those who are receiving Incapacity Benefit, Income Support or both; or Employment and Support Allowance
Not receiving benefits and not working or actively seeking work
Unpaid voluntary work and not working or actively seeking work
Prefer not to say
Are you receiving Statutory Sick Pay?:*
Yes
No
Don't know
Prefer not to say
Are you currently receiving any of the following benefits?:*
JSA
ESA
PIP
Incapacity Benefit
Universal Credit
None
Would you like support with any employment related difficulties you may be having?:*
Please Select A Value...
Yes - returning to work
Yes - staying in work
Yes - career support
Yes - finding employment
No employment support required
Are you taking any Medication for your Mental Health Issues? For example - antidepressants, these may include Fluoxetine, Sertraline, Citalopram:*
Prescribed but not taking
Prescribed and taking
Not Prescribed
Don’t know
Prefer not to say
Do you need any assistance from a translator to access therapy?:*
Yes
No
If yes, please specify the language:
Please Select A Value...
Akan (Ashanti)
Albanian
Amharic
Arabic
Bengali & Sylheti
Brawa & Somali
British Signing Language
Cantonese
Cantonese and Vietnamese
Creole
Dutch
English
Ethiopian
Farsi (Persian)
Finnish
Flemish
French
French creole
Gaelic
German
Greek
Gujarati
Hakka
Hausa
Hebrew
Hindi
Igbo (Ibo)
Italian
Japanese
Korean
Kurdish
Lingala
Luganda
Makaton (sign language)
Malayalam
Mandarin
Norwegian
Pashto (Pushtoo)
Patois
Polish
Portuguese
Punjabi
Russian
Serbian/Croatian
Sinhala
Somali
Spanish
Swahili
Swedish
Sylheti
Tagalog (Filipino)
Tamil
Thai
Tigrinya
Turkish
Urdu
Vietnamese
Welsh
Yoruba
Other
Do you have any accessibility requirements?:*
None
Hearing
Sight
Speech
Mobility
Do you have any of the following Long Term conditions?:*
None
Asthma
Cancer
Chronic Pain
COPD
Dementia
Diabetes
Digestive Tract conditions
Epilepsy
Heart Failure
Hepatitis
HIV
Long Covid
Medically Unexplained Conditions
Musculoskeletal Disorder (MSK)
Other Respiratory Disease
Skin Condition including Eczema
Are you still struggling with physical symptoms more than 4 weeks after contracting Covid 19?:
Yes
No
Please explain symptoms:
Ethnicity:*
Please Select A Value...
White - British
White - Irish
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Any other Asian background
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Any other Black background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
National Identity:*
Please Select A Value...
British
English
Irish
Scottish
Welsh
Other
If Other, please specify:
Religion/Belief:*
Please Select A Value...
Baha'i
Buddhist
Christian
Hindu
Jain
Jewish
Muslim
Pagan
Sikh
Zoroastrian
Any other religion
None
Declines to Disclose
Patient Religion Unknown
Sexuality:
Please Select A Value...
Heterosexual
Lesbian or gay
Bisexual
Other
Not known
Not stated
Relationship Status:*
Please Select A Value...
Single
Married
Divorced
Widowed
Separated
Co-Habiting
Long term
Civil Partnership
Not Disclosed
British Armed Forces:*
Please Select A Value...
Yes - ex services
No
Dependant of a ex-serving member
Not stated (Person asked but declined to provide a response)
Unknown (Person asked and does not know or isn't sure)
Tick any that apply to you:
Pregnant
Partner pregnant
Family with child under one year
Family with children under one year
Family with child under two years
Family with children under two years
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.
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