Referral Form

Please note that referrals can be made on behalf of someone else with their consent. Please ensure that the individual is fully aware that you are making the referral.

If you are a Health Care Professional wishing to make a referral for a client, please DO NOT use this Self Referral form. Please instead, email: nhsnwl.hounslowiapt@nhs.net to request a HCP Referral Form.

Fields marked with a * are required.

Title*

Your given first name (in full):*

Your preferred name:

Your surname:*

Gender:*

What are your preferred pronouns? (ie he/him, she/hers, they, etc):

Date of Birth (DD/MM/YYYY):*

Address line 1:*

Address Line 2:

Town:*

County:*

Postcode:*

Email:*

Please note, in an attempt to save the planet Hounslow IAPT are making every effort to go paperless. You will therefore receive correspondence via secure email. Should you have any difficulties with this, please indicate you prefer to receive letters by post.

If you do not have an email address, please input the following: noemail@nhs.net

Please specify:*

I consent to receiving correspondence via email

I prefer to receive correspondence via post

Home Number:

Can we leave a message on this telephone number?

Yes

No

Mobile Number:

Can we leave a message on this telephone number?

Yes

No

Can we send you SMS reminders?

Yes

No

We are only able to accept referrals for those registered with a GP Practice in Hounslow.

Name and address of GP:*

Your NHS No. (if known):

What is your nationality?:*

What is your ethnicity?:*

What is your religion?*

What is your sexual orientation?:*

Are you Ex-British Armed Forces?:*

Disability Status:*

No Perceived Disability

Has Disability

If 'Has Disability' selected, please confirm nature of disability:

Accessibility Information Status:*

If 'Has Accessibility information requirements' please provide details

Are you employed as an NHS Worker?:*

Yes

No

If yes, please state Job Title and Employing organisation:

NB: In the interests of confidentiality, if you are employed by West London NHS Trust, we will forward your referral to Keeping Well to seek a service outside of this Trust to process your referral. For further information visit: www.keepingwellnwl.nhs.uk.

Do you look after anyone (e.g. a family member, partner or friend) who would not be able to cope without your support due to additional needs such as illness, frailty, disability, a mental health problem or an addiction?:*

Yes

No

Does anyone (e.g. a family member, partner or friend) support you due to additional needs such as illness, frailty, disability, a mental health problem or an addiction?:*

Yes

No

If yes: Would you like your carer to be involved in your treatment?:

Yes

No

If yes, please provide the details of your carer below:

Name:

Relationship to patient:

Contact Telephone number:

Address:

Are we able to speak to your carer about this self referral (e.g. if we are unable to contact you):

Yes

No

Who is your Next of Kin? Please provide their name:*

What is their relationship to you?:*

What telephone number can they best be contacted on?:*

Are you happy for us to contact them/speak to them about your treatment?:*

Yes

No

What is the main problem you would like support with?:*

If you have selected Traumatic / distressing experiences, please select one of the following:

If other, please specify below:

Do you have a long-term condition?:*

Are you interested in any specific workshops that we run?:

Yes

No

If yes, which ones?:

My Mind & Bump (Antenatal) Workshop

My Mind & Baby (Postnatal) Workshop

Where did you hear about our service?:*

Are you currently being seen by any Secondary Care Mental Health Services (e.g. Single Point of Access, Crisis and Assessment Team (CATT), Liaison Psychiatry, Recovery Team)?:*

Yes

No

Not sure

If Yes, please give details, including any current or previous diagnosis (if known):

Are you currently taking any antidepressants or anti-anxiety medication?:

Yes

No

If yes, please give the name of the medication and the dosage prescribed:

Are you pregnant or a parent of a child under the age of 18 months?:*

Yes

No

If you are pregnant or postnatal, what is your due date / when was your baby born?:

Do you require a translator/interpreter?:

Yes

No

If yes, what language?:

We are a 9-5 service and are unable to provide urgent support. If you are in need of emergency help or if you are in a crisis, please call 0800 328 4444, call 999, or present to your local A&E so your treatment is not delayed.