Referral Form

Please note that in order to access our service you will need to either be a resident, or be registered with a GP, in the London Borough of Hammersmith & Fulham. If you are unsure which IAPT service covers your area, please either use this link https://www.nhs.uk/Service-Search/Psychological therapies (IAPT)/LocationSearch/10008 or arrange to speak to your GP.

In response to the COVID-19 pandemic, if you work for the NHS or in a care setting in North West London you will be eligible for priority access to support, to access this, please complete the below referral form. For further information visit: http://www.keepingwellnwl.nhs.uk

*Hammersmith & Fulham, Hounslow, Ealing, Harrow, Brent, Kensington & Chelsea, Westminster, Hillingdon.

Back on Track is not an emergency service and this referral form should not be used if you require urgent support. If you are worried about immediate risk of harm to self or others, please speak to your GP. Alternatively, you can also contact the following services 24 hours a day, 7 days a week: West London Health Trust Helpline (0800 328 4444) NHS Helpline (111), and the Samaritans (116 123).

In taking your details, we recognise the importance of personal privacy and make sure all information about you is held securely in accordance with the General Data Protection Regulation (GDPR)

We use data anonymously for monitoring purposes. However, no one will be able to link any information back to you.

Everything you tell us is kept confidential, however if you disclose information concerning current or potential harm or risk to yourself or another, we may need to tell another party including your GP, the Police or Ambulance Service.

Please confirm that you agree with these terms and conditions:*

Yes

* indicates required field

Please indicate whether this is a:*

Referral for yourself

Referral from a Health Care Professional

If Referral from a Health Care professional is selected, please complete the below details

Referrer name:

Referrer department:

Referrer telephone number:

Referrer email:

Title:*

First Name:*

Last Name:*

Date of Birth:*

Gender:*

Address Line 1:*

Address Line 2:

Town/City:*

Postcode:*

Email:

Please note: We use your email address to confirm appointments only. If you do not have an email address, please input the following: noemail@nhs.net

Mobile Telephone Number:

Is it OK to leave a voicemail on your mobile number?:

Yes

No

Is it OK to sent text to your mobile number?:

Yes

No

Other Telephone Number (EG: work, home):

Is it OK to leave a voicemail on your other number?:

Yes

No

GP Name:

GP Surgery Name:*

Permission to Contact GP?:*

Yes

No

Your GP holds a duty of care for you. We find it helpful for people when we keep their GP up to date about whether they are accessing our service, so that they can co-ordinate your care appropriately.

Please be aware that at times we may need to contact your GP without your consent, in the interests of promoting safety. If we are concerned about yours, or others safety, we will need to let your GP know about this as they hold a duty of care for your wellbeing.

Please see our webpage on ‘Problems We Treat’ for information about the areas that we can and cannot support people with. Please visit: https://www.backontrack.nhs.uk/who-we-see/problems-we-treat/

Why do you want to refer yourself to Back on Track?:*

If 'other', please specify or use this space to provide a brief description of your problem:

What type of therapy are you interested in accessing?

We offer a range of options for delivery of therapy. Please see our ‘What we offer’ page for full details, if you have not had the chance to look already. Please make sure to open this in a separate tab so that you don’t lose the information you have already provided. Please visit: https://www.backontrack.nhs.uk/what-we-offer/

Back Online is a digital way of accessing therapy flexibly, with the freedom to fit this in to hectic schedules.

Our courses and workshop options are a great opportunity to learn skills in managing mood with the support and ideas of other people experiencing similar difficulties.

Please select an option:*

Please select your first choice, and if there are any further treatment options you would be interested in please enter them in the free text box below. A therapist will be able to discuss these with you during your assessment. Please do not complete multiple self-referral forms.

Second therapy option you would be interested in:

Please note if you have been signposted to our workshops via a community organization, it is really important to provide the code they gave you so that we can support you in accessing this promptly. Further support can be discussed following this workshop.

Are you being seen by any other service for mental health problems?:*

Yes

No

If you answered yes, please give details:

Have you ever been seen by any other service for mental health problems?:*

Yes

No

If you answered yes, please give details:

Where did you hear about us?:

What is your Nationality?:*

What is your preferred language?:*

Do you speak English?:*

Yes

No

Are you able to understand written English?:*

Yes

No

Do you need a translator?:*

Yes

No

If yes, what language do you need?:

Do you require any additional support in accessing our service?:

If other, please state:

Are you a carer for someone?:*

Yes

No

Do you have a carer?:*

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

What is your ethnicity?:*

What is your religion?:*

What is your sexual orientation?:*

Do you have a disability or long-term health condition?:*

Yes

No

If yes, what is it?:

If other, please specify:

Do you have any of the following medically unexplained symptoms?:*

Are you an ex-member of the British Armed Forces?:

In order to make our service accessible to your needs, please let us know if you are:

Currently pregnant, or

Have a child under 12 months old

If we think we may be able to help you we will offer you an assessment appointment with one of our team. If we think that you could benefit from a different service we will contact you to let you know. If we decide that we are not the right service to offer you therapy, we may send your referral to another service that may be more appropriate for you within our Trust.

If you have questions about how we manage your information, you are welcome to discuss these with any staff member involved in your care.

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Referral Form

Referral

Your Details

GP Details

Referral Information

Further Information

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