Referral Form

Personal Details

NHS Number (if known):

All patient registration information and clinical contact details will be stored on IAPTUS, IAPT's medical record system which is separate from your general medical records. If you wish to access the service then consent will need to be given for your data to be stored for clinical use within our service.

Consent for Data Storage:*

Yes

All information sent to the DoH is coded and completely confidential and is aimed at ensuring quality of care from the service is being monitored externally. This means a randomly assigned number and your questionnaires measures are sent anonymously to the Department of Health without any information with which to identify the person involved.

By referring yourself we assume consent for the date to be sent, if this is not the case then please contact us on 0300 9991616.

Title:*

First Name:*

Last Name:*

Gender:*

Male

Female

Not specified

Not known

Pronouns:*

Date of Birth:*

Please note there is an age restriction of 17 years and 6 months in place.

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Mobile Number:*

Permission to leave voicemail?*

Yes

No

Precautions:

Permission to contact by SMS?*

Yes

No

Home Number:

Permission to leave voicemail?

Yes

No

Precautions:

Email Address:*

Permission to send email?*

Yes

No

Would you like to provide an emergency contact?*

Yes (please provide details below)

Declines to provide

First Name:

Last Name:

Relationship:

Telephone number:

Notes:

Are you currently a staff member from NHFT, NGH, KGH, Milton Keynes or Bedfordshire Talking Therapies service?

Yes

No

Nationality Identity:*

Ethnicity:*

Do you have a disability?*

Yes

No

If yes, please specify below:

Do you have a long term condition?*

Yes

No

If yes, please specify below:

If you would prefer to find out more about the service, or other options for support within Northamptonshire and pick up some new techniques to start your therapy immediately then you may want to access the welcome webinar as they run weekly.

There are also a number of single workshops to access support and strategies without the need for an initial assessment for ease of access.

Please select the workshop if you would like to attend:

If you do not indicate any of the above, you will be contacted by the service to arrange an assessment.

Where did you hear about us?

Please complete the captcha

NHS Northamptonshire Talking Therapies Self Referral Form

Personal Details

Further Details