PLEASE NOTE: If you do not receive a ‘successful submission’ message after clicking the submit button then an error has occured. Please try again or contact TalkPlus on 01252 533355 (in office hours) or email nehccg.talkplus.org.uk

SELF-REFERRAL AND OPT-IN

You may use our web site freely but you can only self-refer if your GP is in Yateley, Fleet, Farnborough, Blackwater, Aldershot or Farnham.
Please complete all the details in the form below and then click the 'Submit' button.
You should make sure that:
- you double check any telephone numbers you give us as we will use them to contact you;
- all fields must be completed otherwise you will not be able to click the 'Submit' button

Remember, to self-refer your GP must be in Yateley, Fleet, Farnborough, Blackwater, Aldershot or Farnham

YOUR CURRENT DIFFICULTIES

YOUR GOALS

YOUR PREVIOUS or CURRENT HEALTHCARE

(e.g. CMHRS, Psychiatrist or other Therapist)

Your answers to the following questions will help us assess your current condition. Your referral cannot be submitted until this section is fully completed.
Please indicate how often you have been bothered by the following problems over the last two weeks:

PHQ9

If you have chosen 1,2 or 3 on the last question, please answer the following question:

GAD7

PHB

On a scale of 0-8, please select a number to indicate how much you would avoid the following:

WSAS

On a scale of 0-8, please select a number to indicate how much your problems impact on the following areas of your life:
PLEASE NOTE:
We may use and share your NHS Number and non-identifiable data about your treatment to provide statistics on the performance and effectiveness of our service with NHS England, NHS Digital and the local NHS Clinical Commissioning Group relevant to your area.