GP and healthcare professional referrals
Please note that we don’t accept referrals online from secondary care mental health services.
Steps2Wellbeing is a service people aged 18 years and over, registered with a GP in Dorset or Southampton City.
Referrer's Details
Referrer Name:*
Referrer source (professional role):*
Referrer contact email:*
Referrer Telephone number:*
Please confirm that the patient is aware and consents to the referral:*
Yes
Patient’s Details
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Mx
Dr
Rev
Prof
Lady
First Name:*
Last Name:*
Date of Birth:*
Gender:*
Male
Female
Other
Not known
NHS Number:
House Name/No:*
Address:*
Town/City:*
County:*
Postcode:*
Email:
GP Surgery:*
Mobile Number:
Can a voicemail be left on this number?:
Yes
No
Can an SMS be sent to this number?:
Yes
No
Landline number (if you do not wish to provide a landline number please enter 0000000000):*
Can a voicemail be left on this number?:
Yes
No
Note: Please complete at least one contact number
Further Details
Is the patient ex-British Armed forces?:*
Please Select A Value...
Yes - ex services
Dependant of an ex-serving member
No
Not stated (Person asked but declined to provide a response)
Unknown (Person asked and does not know or isn't sure)
Is the patient or their partner expecting a child?:*
Yes
No
Does the patient have a child/children under the age of 24months?:*
Yes
No
Is the patient currently under the care of any other mental health service?:*
Yes
No
If "yes" please give details:
Nationality:*
Please Select A Value...
British
English
Irish
Scottish
Welsh
Other
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 backgrond
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated - I do not wish to state
Not known - Not known
Sexual orientation:*
Please Select A Value...
Heterosexual
Lesbian or gay
Bisexual
Other
Unknown
Declined to Respond
Relationship Status:*
Please Select A Value...
Single
Married
Divorced
Widowed
Separated
Co-Habiting
Long term
Not Disclosed
Civil Partnership
Does the patient suffer from any long-term health conditions?:*
Chronic Pain (Any pain lasting beyond 3 months, Migraines, MSK, Chronic back pain, Endometriosis Rheumatoid Arthritis, Fibromyalgia, Phantom limb pain)
ME/CFS
Medically unexplained conditions
Respiratory (COPD/Bronchiectasis/Severe or Brittle Asthma, Sarcoidosis Fibroma Pulmonary Fibrosis Cystic Fibrosis Emphysema)
Coronary heart disease (CHD), Cardiovascular Disease, & heart attack
Diabetes
Long Covid
Gastro & bowel disease, IBS, IBD (Crohns Disease, Ulcerated Colitis)
Stroke & TIA
Other (Please state in box)
No long-term health conditions
Please list long term conditions not ticked above:
Does their long term health condition impact on their mental health or vice versa?:*
Yes
No
Does the patient have any additional accessibility requirements?:*
Yes
No
If "yes" please give details:
Current medication:*
Preliminary diagnosis:*
History (including risk):*
PHQ9 (if available):
Please Select A Value...
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
GAD7 (if available):
Please Select A Value...
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
Reason for referral:*
What is the patients Employment Status?:*
Please Select A Value...
Employed full-time
Employed part-time
Unemployed
Full-time student
Retired
Full-time homemaker or carer
Long-term sick or disabled, those who are receiving Incapacity Benefit, Income Support, or both
Unpaid voluntary work who are not working or actively seeking work
Not receiving benefits and who are not working or actively seeking work
Not stated
Is the patient currently attending work as normal?:*
Please Select A Value...
Employed and in work
Employed and off sick
Employed and working reduced hours
N/A - Not employed
How many hours does the patient work a week?:*
Please Select A Value...
30+ hours
16-29 hours
5-15 hours
1-4 hours
Not known
Is the patient currently receiving sick pay?:*
Please Select A Value...
Yes
No
Not stated
Unknown
Which of the following benefits id the patent currently receiving?:*
JSA
ESA
PIP
Incapacity Benefit
None
Would the patient like support with employment related difficulties?:*
Please Select A Value...
Yes - returning to work
Yes - staying in work
Yes - career support
Yes - finding employment
No employment support required
Please complete the captcha
Submit
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