Referral Form

Referrer Details

Name:

Team:

Role:

Email Address:

Contact Number:

NHS Number:*

Title:

First Name:

Last Name:

Gender:

Male

Female

Not specified

Not known

Sexuality:*

Preferred Pronoun:

She/Her

He/Him

They/Them

Prefer to self describe below

Self described pronouns:

Ethnicity:*

Religious or Belief Affiliation:*

Date of Birth:

Address Line 1:

Address Line 2:

Town/City:

County:

Postcode:

GP Surgery:

Home Number:

Do we have permission to leave voicemails on this number?:

Yes

No

Mobile Number:

Do we have permission to leave voicemails on this number?:

Yes

No

Do we have permission to send text messages?:

Yes

No

Email Address:

Access requirements (physical disability, learning disability, language, literacy, etc):

We can now also accept referrals for 16 and 17 year olds. We ask for anyone under the age 18 accessing our service to provide the name and contact details of a responsible adult (someone 18+). This is someone that if we did have immediate concerns regarding their safety, they would feel most comfortable us sharing that information with. Should this happen we would always try and ensure the patient is informed and as involved in this process as possible. This person could be a parent or carer, older sibling, grandparent or school teacher for example and they would only be contacted if we have any immediate concerns for their safety.

Would you like to give us the name of a responsible adult?*:

Yes

No

If yes, please specify their name, contact number and relation to you:

Diagnosis or suggested diagnosis:

Cluster:

Summary of the presenting problem:

Relevant Developmental History:

Any past psychological therapy?:

Describe any past contact with mental health services:

Has the patient ever had a severe mental illness such as psychosis, bipolar disorder or a personality disorder:

As the referrer, what are you hoping will be achieved from a brief psychological intervention?:

Current and past risk and any Risk Management plan:

We prioritise veterans, perinatal women, victims of nationally declared disasters, and people whose urgent medical treatment is delayed by a phobia. Does this patient fit into these categories and how?:

Long term medical condition? (e.g. cancer, diabetes, heart disease, stroke). If so please describe the nature of the condition:

Scores on any questionnaires used (e.g. PHQ-9, GAD-7, IES-R):

Details of other professionals involved:

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Professional Referral to NHS Somerset Talking Therapies

Referrer Details

Patient Details

Nominated Adult - for patients aged 16 and 17

Presentation

Goals

Risk Assessment

Priority Status

Any other relevant information