Refer Yourself
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
Referral
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:
Your Details
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Mx
Dr
Prof
Rev
First Name:*
Last Name:*
Date of Birth:*
Gender:*
Male
Female
Not known
Not specified
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 Details
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.
Referral Information
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?:*
Please Select A Value...
Anxiety linked to excessive worry (Generalised Anxiety Disorder)
Anxiety linked to having Panic Attacks
Anxiety linked to specific situations like crowded spaces (Agoraphobia)
Anxiety linked to social situations (Social Phobia)
Anxiety linked to a Specific Phobia of (please detail below)
Anxiety linked to worry about my health (Health Anxiety)
Bereavement
Body Dysmorphic Disorder (BDD)
Low Mood/Depression
Obsessive Compulsive Disorder (OCD)
Mixed Depression & Anxiety
Post Traumatic Stress Disorder (PTSD)
Other
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 A Value...
Building self-esteem Course (Weekly evening sessions for 12 weeks)
Improve Your Mood Course (Weekly evening sessions for 9 weeks)
Mindfulness Based Cognitive Therapy Course (Weekly evening sessions for 8 weeks)
Overcoming Social Anxiety Course (Weekly evening sessions for 10 weeks)
Stress Control Course (Weekly sessions for 6 weeks)
Back Online
Individual Therapy Appointments
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?:
Further Information
What is your Nationality?:*
Please Select A Value...
British
English
Irish
Other
Scottish
Welsh
What is your preferred language?:*
Please Select A Value...
Akan (Ashanti)
Albanian
Amharic
Arabic
Bengali & Sylheti
Brawa & Somali
British Signing Language
Cantonese
Cantonese and Vietnamese
Creole
Dutch
English
Ethiopian
Farsi (Persian)
Finnish
Flemish
French
French creole
Gaelic
German
Greek
Gujarati
Hakka
Hebrew
Hausa
Hindi
Igbo (Ibo)
Italian
Japanese
Korean
Kurdish
Lingala
Luganda
Malayalam
Makaton (sign language)
Norwegian
Mandarin
Pashto (Pushtoo)
Patois
Polish
Portuguese
Punjabi
Russian
Serbian/Croatian
Sinhala
Somali
Spanish
Swahili
Swedish
Sylheti
Tagalog (Filipino)
Tamil
Thai
Tigrinya
Turkish
Urdu
Vietnamese
Welsh
Yoruba
Other
Do you speak English?:*
Yes
No
Do you need a translator?:*
Yes
No
If yes, what language do you need?:
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?:*
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 background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Other Ethnic Groups - Japanese
Other Ethnic Groups - Vietnamese
Other Ethnic Groups - Filipino
Other Ethnic Groups - Arab
Other Ethnic Groups - Iranian
Other Ethnic Groups - Iraqi
Other Ethnic Groups - Middle Eastern
Other Ethnic Groups - Columbian
Other Ethnic Groups - Ecuadorian
Other Ethnic Groups - Other Latin American
Not Stated - Not Stated
Not known - Not known
Do you have a disability or long-term health condition?:*
Yes
No
If yes, what is it?:
Please Select A Value...
Arthritis
Asthma
Cancer
Chronic Fatigue
Chronic Kidney Disease
Chronic Obstructive Pulmonary Disease (COPD)
Chronic Pain (including Fibromyalgia)
Chronic Pancreatis
Coronary Heart Disease
Crohn’s Disease
Dementia
Diabetes
Eating Disorder
Epilepsy
Hypertension / high blood pressure
Irritable Bowel Syndrome
Medically Unexplained Symptoms
Musculoskeletal disorder (MSK)
Osteoporosis
Parkinson’s Disease
Severe Mental Health Problems
Stroke and Transient Ischaemic Attacks
Thyroid problems
Other
None
Decline to say
Do not know / not sure
If other, please specify:
Are you an ex-member of the British Armed Forces?:
Please Select A Value...
Yes - ex services
No
Dependant of a ex-serving member
Not stated (Person asked but declined to provide a response)
Unknown (Person asked and does not know or isn't sure)
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
What will happen next
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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