Referral Form

We are not a crisis service. If you need immediate help to keep yourself or others safe please call NHS 111, your GP, or go to your local Accident & Emergency department. If you feel yourself or others are at imminent risk of physical harm please call 999.

By completing and submitting this form you are consenting for your information to be stored on our confidential service database. This information is held securely and is not viewed by anyone outside of Turning Point.

Please be aware if you do not give consent, we may still need to speak to other professionals if we feel there is any risk of harm to or from yourself or others, or where a crime has been committed. We would always try to contact you first before making such a decision.

* = Mandatory Fields

*We are required to share anonymous statistical data with the Department of Health. No personal identifiable information or content of therapy is shared in this process and doing so helps us to improve our services. Please select if you give consent for us to do this:

*Do you consent for your GP and other relevant health professionals to be kept up to date with relevant information about your care?

*Title

*First Name

*Last/Family Name

*Date of Birth

*Gender

Male

Female

Would prefer not to say

Not known

*Address Line 1

Address Line 2

*Town/City

County

*Postcode

*Permission to Send Written Communication by Post?

Yes

No

Telephone Number (Home):

Permission to leave Voicemail

Yes

No

Telephone Number (Mobile):

Permission to leave Voicemail

Yes

No

Permission to call, text message and email for contact and reminders of appointments:

Yes

No

Are there any days and times that you absolutely cannot be contacted:

Do not contact (day)

Do not contact (time)

Morning

Afternoon

Evening

Email (if known):

Permission to Contact by Email?

Yes

No

Please provide your NHS Number (if known):

*GP Name

*GP Practice

GP Contact Number

*Nationality

*Ethnicity

Sexuality

*Do you have any disability we should be aware of?

Yes

No

If yes, please select the most appropriate from the list:

Any other notes relating to your disability:

*Do you have refugee/asylum seeker status?

Yes

No

*Are you able to read and write in English?

Yes

No

*Do you have any special requirements such as autism, Asperger’s syndrome, ADHD we should be aware of?

Yes

No

*Do you require an interpreter?

Yes

No

If yes, which language is required?

*Do you suffer with any Long Term Medical Conditions (e.g. Diabetes, Chronic Pain) which affects your day to day life?

If yes, please select

*Are you currently pregnant or do you have a child under the age of 1?

Pregnant

Child aged under 1

None

*Do you look after any dependents, such as children or elderly/disabled family members?

If yes, what are their names, date of birth, and relationship to you:

*Are you an ex-British Armed Forces member?:

*Please provide briefly the reason(s) for your referral. Please could you describe the mental health issue that you would like help with and how it is affecting you?

*Are you currently receiving any support (e.g. medication or therapy) for this issue?

Yes

No

*In an average week, how much alcohol do you drink?

*Do you currently use any recreational substances such as Cannabis, Cocaine, Ketamine, MDMA, M-KAT or legal highs? How often do you use these and in what quantity?

*How did you find out about our service?

If other, please specify

We will endeavour to look at all online referrals within 48 hours, after which we will attempt to make telephone or email contact with you in order to arrange for an assessment.

Please be aware if you do not give consent, we may still need to speak to other professionals if we feel there is any risk of harm to or from yourself or others, or where a crime has been committed. We would always try to contact you first before making such a decision.

By completing and submitting this form you are consenting for your information to be stored on our confidential service database. This information is held securely and is not viewed by anyone outside of Turning Point.

Please complete the captcha

Self Referral Form

Personal Details

Additional Information

About You