Referral Form

TALKWORKS, Devon’s NHS Talking Therapies Service, offers free and confidential psychological therapy. We are here to help adults, age 18+, living in Devon (outside Plymouth), who may be experiencing a common mental health problem such as stress, anxiety, depression or insomnia. We offer a range of talking therapies and treatment options to help get you back on track and feel more like yourself again.

If you are GP or healthcare professional working with a patient that you feel may benefit from our services, you can, with their knowledge and consent, refer them to TALKWORKS by filling out the form below. Following triage of the referral, a member of our team will then be in touch with the patient to arrange an initial assessment with one of our clinicians. We may contact you if we need more information or if we think we are not the most appropriate service.

PLEASE NOTE – IF YOU ARE A DPT OR CFHD EMPLOYEE, YOU MUST COMPLETE ALL ADDITIONAL MANDATORY FIELDS. MISSING INFORMATION WILL LEAD TO THE FORM BEING RETURNED TO YOU REQUESTING MORE DETAIL.

Your name:

Your job title and organisation or service:

Your email address:

Your phone number:

Are you an employee of Devon Partnership Trust or Child and Family Health Devon?

Yes

No

Please confirm you are aware of the needs that TALKWORKS can and can’t meet, as described here (www.talkworks.dpt.nhs.uk/nhs-mental-health-support/our-nhs-support).

Please confirm that you believe TALKWORKS are able to meet this person’s needs?

Yes

No

Title of the patient:*

Patient’s first name:*

Patient’s last name:*

Patient’s date of birth: (TALKWORKS is a service for people aged 18 and over):*

Patient’s gender:*

Please outline the problems/difficulties that the patient is experiencing and the reason for the referral:

The following five fields are mandatory for DPT and CFHD referrers. Other referrers are free to add information here if it is known.

Please provide details from most recent Mental Health assessment or contacts, including diagnosis, symptoms, psychological formulation and details of past treatment and/or therapy:

Current presenting situation, including living arrangements, employment status, social support, and level of stability including any relationship or family issue or concerns:

Mental Health History: Include any relevant family history, mental health history - including trauma, previous mental health treatment and engagement:

RISK: Please summarise risk assessment and management plan, including current and historic risks to self and to and from others, safeguarding matters, and known/historic substance use:

Are any other agencies involved in the person’s care, e.g. Probation, Drug and Alcohol Services, Social Services etc? If yes, please give details:

Patient’s Address Line 1:*

Patient’s Address Line 2:

Patient’s City / Town:*

Patient’s Postcode:*

Patient’s Email address:*

Patient’s Mobile phone number:

Can we leave a voicemail on this number?:

Yes

No

Patient’s Landline number:

Can we leave a voicemail on this number?:

Yes

No

If we are unable to leave a voicemail and we are unable to speak to the patient, we will contact them via email instead.

Please tick here to confirm if the patient is happy to receive appointment information and reminders from us by text message:

Yes

Patient’s GP’s name:

Patient’s GP’s surgery: *

We are required to let the patient’s GP (doctor) know that they are coming along to see us. If the patient does not know the name of their GP, you can leave this blank and just include the surgery name.

For the initial appointment would the patient prefer (please tick any that apply):

A face-to-face appointment

A telephone appointment

A video call appointment

No preference

Does the patient have any additional needs that we need to be aware of? (e.g. mobility needs, sight or hearing difficulties, an interpreter if English is not their first language):

Yes

No

If 'Yes', what help do they need?

TALKWORKS often employ clinicians who are undertaking clinical training. All our trainee practitioners have passed robust competency assessments at Exeter University, and are closely supervised by qualified and experienced members of our team. The patient’s confirmation letter will let them know if their initial appointment is booked with a trainee. If they have any concerns about this, they can call us on 0300 555 3344.

The patient’s ethnicity:*

The patient’s sexuality:*

Does the patient have a disability?

Is the patient a carer? (for someone other than a child):

Yes

No

Does the patient currently experience any difficulties with reading or writing?

Yes

No

If 'Yes", please tell us more about this if you are able to:

Does the patient have a long-term physical health condition that impacts on their mental health?

Yes

No

If 'Yes', please tell us a bit more about their long term health condition:

Is the patient currently pregnant or do they have a child under the age of two years old?

Yes

No

Does the patient have any current involvement with the Probation Service?

Yes

No

If they have answered YES, we will need to contact the Probation Service before we can proceed with booking an appointment for the patient.

Please tick here to confirm they consent to us doing so:

Yes

Is the patient either currently seeing anyone from any other mental health or drug and alcohol service, have they recently (in the last 12 months) been involved with another service, or are they waiting to see another service?

Yes

No

If 'Yes', please provide any details you can about the people or services they have recently seen, or any treatment they have recently had, or any services they are waiting to access:

In the event of an emergency, please provide the details of someone close to the patient who we can contact:

First name:

Last name:

Phone number:

Relationship to patient:

Please confirm the person consents to this referral and agrees to be contacted by TALKWORKS to progress their referral to the service:*

Yes

We share information with the Department of Health to ensure that our service is accessible to all and meets national quality standards. This data is transferred and used securely and it is impossible to identify any individual person in the national statistics. If the person you are referring has any concerns about this, or would like to be excluded from this data, the patient will need to let the clinician know when they meet with them. Their details will be retained on our secure electronic system. If the person being referred has any concerns about this, they can discuss this when we contact them.

Please complete the captcha

GP / HEALTHCARE PROFESSIONAL FORM

Step 1: Referrers Details

Step 2: About the person

Step 3: Contact Details

Step 4: The patient’s appointment

Step 5: Please tell us a bit more about the patient