Referral Form

Please complete this form if you would like help from our service. Our NHS-funded therapies are for people aged 16+ who are registered with a GP Practice in Cornwall & the Isles of Scilly.

When you submit this form, a member of our team will make contact within five working days to arrange an appointment.

If you are a GP or health professional referring a patient, please complete the form and we will contact the patient within five working days. If we cannot contact the patient, we will inform you within 15 working days.

Please indicate if you are referring yourself or a patient:*

I am referring myself

I am a GP or health professional referring a patient

If you are a GP or health professional, please provide your name, role and contact details:

Title:*

First Name:*

Preferred Name:

Surname:*

Date of Birth:*

Gender identity:*

Male

Female

Not specified

Not known

Address line one:*

Address line two:

Town:*

County:*

Postcode:*

Please select the times when we can best reach you by phone to arrange an appointment. We will be calling from a withheld number and will only speak to you/the patient (unless you give permission to speak with anybody else):*

If someone else answers can we leave a message with them and disclose where we are calling from?:*

Yes

No

If yes, please give their name(s):

Landline phone number (leave blank if not applicable):

Landline phone number type:

Is it ok to leave a voicemail message?:

Yes

No

Mobile Number:

Is it ok to leave a voicemail message?:

Yes

No

Can we send you SMS text messages?:

Yes

No

Email:*

Confirm Email:*

We routinely provide questionnaires by email for you to complete before your appointment.

If you are unable to receive questionnaires by email, please indicate here:

I am unable to receive questionnaires by email

Registered GP surgery:*

GP Name (if known):

GP Surgery Address (if known):

Please be aware that we are not an emergency service. If you feel that you are in crisis or in need of more urgent support, please contact your GP or the Community Mental Health Team on 0845 207 7711.

Out of hours crisis numbers;

- Nightlink - Freephone 0808 8000 306

- Samaritans - Freephone 116 123

Please provide a brief description of the current difficulties you are experiencing that you would like to address.

Reason(s) for referral:*

Are you currently involved with the Community Mental Health Team (CMHT)? Or have been involved within the last year?:*

If yes, to ensure you receive the right level of care for your needs, do we have permission to liaise and request information from the Cornwall Foundation Trust?:

Do you need any assistance from a translator to access our service?:*

Yes

No

Do you have any disabilities?:*

Is there any way in which we can personalise our service for you to make the experience easier? e.g. forms in large print, wheelchair access etc.:

Do you have any long term medical conditions?:*

Long Term medical condition(s):

Ethnicity:*

National Identity:*

If Other, please specify:

Religion/Belief:*

Sexual Orientation:*

Relationship Status:*

British Armed Forces:*

Are you or have you been pregnant or had a baby in the last 12 months?:

Are you a mum with a child under 3 years old?:

How did you become aware of Outlook South West?:*

By submitting this online referral form, you are agreeing to share your data with the NHS. For more information on how we collect, store and use your data – please see www.outlooksw.co.uk/use-personal-information

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