Self Referral Form
V2
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*
Please choose
Mr
Mrs
Miss
Ms
Dr
Prof
Mx
Rev
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*
Male
Female
Trans Male
Trans Female
Non-Binary
Not known
Other
Prefer not to disclose
National identity*
Please choose
British
English
Irish
Scottish
Welsh
Other
Ethnicity*
Please choose
White - White British
White - White Irish
White - White Polish
White - White Scottish
White - White Any Other Background
Asian or Asian British - Any other Asian background
Asian or Asian British - Bangladeshi
Asian or Asian British - Pakistani
Asian or Asian British - Indian
Asian or Asian British - Tamil
Black or Black British - Any other Black background
Black or Black British - African
Black or Black British - Caribbean
Mixed - Any other mixed background
Mixed - White and Asian
Mixed - White and Black African
Mixed - White and Black Caribbean
Other Ethnic Groups - Any other ethnic group
Other Ethnic Groups - Chinese
Not Stated - Not stated
Religious group*
Please choose
No religious group or secular
Baha'i
Buddhist
Christian
Hindu
Jain
Jewish
Muslim
Pagan
Parsi / Zoroastrian
Sikh
Any other religion
Declines to Disclose
Sexuality*
Please choose
Heterosexual
Male homosexual
Female homosexual
Bisexual
Sexually attracted to neither male nor female sex
Unknown
Unwilling to disclose
Relationship status*
Please choose
Single
Married
Divorced
Civil Partnership
Long term
Co-Habiting
Separated
Widowed
Prefer not to disclose
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*
Please choose
Monday
Tuesday
Wednesday
Thursday
Friday
Any day
Preferred time of day*
Please choose
Morning
Afternoon
Evening
Any time
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?
Please choose
Yes I am
Yes my partner is
No
I prefer not to say
Do you have a child under the age of 2?
Please choose
One child under 2
Children under 2
I prefer not to say
Do you have a disability that we need to be made aware of?
Please choose
Yes
No
I prefer not to say
If yes, please specify
Have you been diagnosed with a long term condition that we should be aware of?
Please choose
Yes
No
Not sure
If yes, please specify
Asthma
Cancer
Chronic Fatigue Syndrome/Myalgic Encephalopathy (ME)
Chronic Obstructive Pulmonary Disease (COPD)
Chronic Pain, Fibromyalgia, MSK
Diabetes Type 1
Diabetes Type 2
Heart Related Condition/Cardiovascular (Heart Disease)
Irritable Bowel Syndrome
Long COVID (diagnosed only Post COVID 19 syndrome)
Medically Unexplained Symptom - diagnosed only eg. Functional Neurological Disorder
Neurological Condition eg. Epilepsy/Stroke/MS
Reproductive/Gynaecological Health eg. Menopause
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
Please choose
Carer
Cousin
Friend
GP
Grandparent
Health Visitor
Housing officer
Mental health worker
Midwife
Parent
Partner
Sibling
Social worker
Son/Daughter
Spouse
Work
Have you (or do you depend on someone who has) served in the British military?*
Please choose
No
Yes - ex services
Dependant of a ex-serving member
Unknown (Person asked and does not know or isn't sure)
Not stated (Person asked but declined to provide a response)
Are you an asylum seeker or refugee?
Please choose
No
I am a refugee
I am an asylum seeker
I prefer not to say
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?*
Please choose
Charity or community group
Council or government department e.g. Job Centre Plus
Event or training
GP
I have used NHS Talking Therapies before
Leaflet or poster
News article
NHS 111
NHS website
Other health or care professional
Radio or TV
School, college or university
Social Media
Web Search
Word of mouth
Other
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.
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