Referral Form

V2

Talking Therapies will contact you by email within 5 working days. If you do not hear from us within this time frame, please call us on 0300 365 2000.

Fields marked with an asterisk * are required.

How did you hear about Talking Therapies?

Do you work for the NHS, a care home or social services?:*

Yes

No

If yes, please select:

Title*

First Name*

Last Name*

Gender*

Address Line 1*

Address Line 2

Town/City*

County*

Postcode*

NHS Number (if known)

Date of Birth*

We can only accept referrals from adults aged 17+

Email*

Although we limit the amount of patient identifiable information we send via email, please note personal email addresses such as Hotmail, Gmail etc. are regarded as non-secure.

Do you consent to us contacting you by email?*

Yes

No

Mobile Number

May we leave a message on this number?

Yes

No

Would you like text reminders of appointments?

Yes

No

Home Number

Would you like to have your initial assessment by telephone or video consultation?*

Please note for video consultations you will need a device with a camera function, internet connectivity and confidential space at the time of your appointment.

Preferred Day(s)*

Preferred Time(s) of Day*

Morning

Afternoon

Please specify a preferred time*

GP Name

Surgery Name*

Please note your GP will be made aware that you have entered the Talking Therapies service.

National Identity*

If Other, please specify:

Ethnicity*

Religious Group*

Relationship Status*

Sexual Orientation*

Are you able to accept short notice appointments?

Yes

No

Please note - a telephone translator and interpreter service is available. Please indicate below if this is required and the language you would prefer to use. A translator will then be available when we telephone you.

Do you require an interpreter?

Yes

No

If yes, please state which language you would prefer:

Are you known to any other Mental Health services?

Yes

No

Do you have a disability that we need to be made aware of?

Yes

No

If yes, please specify:

Do you have a long term condition that we need to be made aware of?

Yes

No

Not sure

If yes, please specify:

If Other, please specify:

Please select any that apply to you:

Are you or your partner pregnant?

Yes I am

Yes my partner is

No

Do you currently have a child or children under 2?

One child under 2

Children under 2

No

Do you consent to provide details for your Next of Kin?*

Yes

No

Please specify the name of your Next of Kin:

Please specify the contact number of your Next of Kin:

Please specify the relationship of your Next of Kin

Have you served in the British Army or are you a dependent of an ex serving member?*

Are you a carer for anyone with a long term condition?

Yes

No

Do you have a probation officer allocated to you?

Yes

No

If yes, please provide the following details of your probation officer so that we can obtain a risk assessment;

Probation Officer Name

Probation Officer Telephone Number

Probation Officer Location

Would you be happy to be contacted by a member of the Talking Therapies service or the research department about any research studies that you might be suitable for?

Yes

No

Please briefly describe your current difficulties (diagnosis if known):*

By completing this form and pressing submit, your details will be stored on our secure confidential system. To find out more about how we use your information please visit the Berkshire Healthcare website to see our Privacy Notice at: https://www.berkshirehealthcare.nhs.uk/protecting-your-data-privacy-notice/

Please complete the captcha

Self Referral Form

Personal Details

First Appointment

GP Details

Demographic Information

Other Information

Referral Information