Self Referral Form

Register for Let's Talk Service

This is available for those registered with Hull GPs only.
For further information about services available in your area please discuss with your GP alternatively you can visit and enter mental health in the search menu where you will find information about services available in your area.
If you are a health professional wanting to transfer care this is not the correct pathway, you will need to email the service accordingly as per professional referral route.
So that we can recommend the most appropriate talking therapy for you we need some information about the kind of problems you are experiencing.
The form will take about 15 minutes to complete.
Please complete all areas of the form in as much detail as you are able to.
There are no right or wrong answers, we want to know how you are feeling and how this may be affecting all areas of your life.
Once you have submitted your form one of our team will review the information you have provided and recommend a treatment.
Where one to one talking therapy is recommended we may suggest that you attend a stress management 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 stress management course
If we need any further information from you to complete your registration with Let's Talk, we will contact you within 7 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)

We may email questionnaires to you during your treatment. These are used to review your progress. They are sent and received securely.

GP Details

Referral Information

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 crisis support on 01482 301701
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 Use of the PHQ-9 may only be made in accordance with the Terms of Use available at 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 crisis support on 01482 301701.


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

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