Referral Form

V2

Complete this form to refer yourself for free and confidential treatment. You can also refer by phone on 0300 365 2000.

We’ll confirm your appointment details by email or send a booking link by text, usually within 5 working days.

We ask questions which help us identify areas where you are affected to ensure that we deliver a service that meets your needs.

If you need urgent mental health treatment, call NHS 111 for advice. If your life is in danger always dial 999.

This form takes about three minutes to complete. Questions marked with an asterisk are required.

Title*

First name*

Last name*

Date of birth (17+ only)*

GP practice name (Berkshire only)*

Your GP will be made aware that you have been referred to Talking Therapies.

Your NHS number (if known)

Address line 1*

City/town*

Postcode*

Email*

Can we email you about your care and treatment?*

Yes

No

We keep the confidential information we send you by email to a minimum due to the risk of details being received by unintended recipients.

Emails from us may go to your spam folder.

Mobile number

We call from a withheld number. Rest assured, we prioritise your privacy on voicemails.

Can we leave a voicemail on your mobile?

Yes

No

Can we send you text messages? (e.g. appointment reminders)

Yes

No

Landline number

Can we leave you a message on your landline?

Yes

No

Gender*

National identity*

Ethnicity*

Religious group*

Sexuality*

Relationship status*

Do you need an interpreter?

Yes

No

If yes, for which language?

Do you have any other access needs e.g. mobility or sight?

Yes

No

If yes, please specify

For video calls you will need a suitable device with a camera and internet connection and a confidential space at the time of your appointment.

How would you like your first appointment to take place?

By telephone

By video call

We can offer an initial 40 minute appointment on weekdays, starting between 8am and 7pm.

Preferred day*

Preferred time of day*

If you have a preferred time, tell us here

Could you accept an appointment at short notice?

Yes

No

Are you, or is your partner, pregnant?

Do you have a child under the age of 2?

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

If yes, please specify

Have you been diagnosed with a long term condition that we should be aware of?

If yes, please specify

LTC Other, please specify

Name of your next of kin

Phone number of your next of kin

Relationship to you of your next of kin

Have you (or do you depend on someone who has) served in the British military?*

Are you an asylum seeker or refugee?

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

Describe your current difficulties, including your diagnosis, if you have one*

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 may be suitable for?

Yes

No

How did you hear about the service?*

If other, please specify

When you submit this form your details will be stored on our secure and confidential health record system. Search ‘privacy notice’ at www.berkshirehealthcare.nhs.uk to find out more about how we use your information.

Please complete the captcha

Self Referral Form