Professionals Referral Form

Milton Keynes Talking Therapies is a primary care service for mild to moderate anxiety and depression.

We cannot treat issues directly relating to:

• Psychosis

• Personality Disorder

• Anger

• Conditions in the presence of an un-managed substance misuse disorder

• Bipolar affective disorder

• Organic or functional neurological disorders

• Anxiety/depression of a complexity such that treatment of longer duration is considered necessary to achieve positive outcome.

Name:*

Designation:*

Telephone:*

Email:*

Title:*

First Name:*

Last Name:*

Gender:*

Male

Female

Not known

Not specified

Date of Birth:*

NHS Number:

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Landline Number:

Permission to leave voicemail:

Yes

Mobile Number:

Permission to leave voicemail:

Yes

Email Address:

Ethnicity:*

Preferred Language:*

Interpreter Required:*

Yes

GP Name:

GP Surgery:*

Details of presenting problem:*

Thoughts of suicide:*

Yes

Any plans/Intent:*

Yes

Previous Attempts:*

Yes

Drug and Alcohol use:*

Yes

If yes give details:

Currently Pregnant:*

Yes

Has child under 24 months:*

Yes

War Veteran:*

Yes

Previous Therapy:*

Yes

Known to secondary MH services:*

Yes

If yes give details:

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Professionals Referral Form

Referral Source

Patients Details

GP Details

Presenting Problem

Additional Information