Referral Form

Please read before completing this form

Talking Mental Health Derbyshire is available to people over the age of 16 years who are registered with a Derbyshire or Derby city GP practice. If you are not a Derbyshire patient, you can search for your local IAPT service here: https://www.nhs.uk/service-search/mental-health/find-a-psychological-therapies-service/find-your-gp. Your GP can also signpost you to a service relevant to your needs if you are not with a Derbyshire practice, or if you are under 16 years of age.

Please be aware that we are not crisis service or an urgent care provider. Please do not complete this form if you require help in a mental health crisis. If you are worried about risk of harm to yourself or anyone else, please speak to your GP or the NHS 111 service if your GP is not available. Additionally, you can contact the following services for support:

Derbyshire Mental Health Helpline: 0800 028 0077

Samaritans: 116 123

SaneLine: 0300 304 7000

Please confirm that you have read and understood the information above:*

Yes, I confirm I have read and understood

Please fill in all the information on this form as completely and as accurately as possible, only skipping the questions which you feel are not relevant to you. Any fields marked with an asterisk (*) require a response.

Title:*

First Name:*

Last Name:*

Date of Birth:*

Gender:*

Male

Female

Non-Binary

Not specified

Is your gender the same as the one assigned at birth?

Yes

No

Prefer not to say

Preferred Pronouns:

Address Line 1:*

Address Line 2:

Town/City:*

County:

Postcode:*

NHS Number (if known):

Mobile Phone Number:

Can we leave voicemails on this number?:

Yes

No

Would you like text message reminders about your appointments?:

Yes

No

Landline Phone Number:

Can we leave voicemails on this number?:

Yes

No

Email Address:

We complete a set of questionnaires at each appointment. Are you happy to receive these by email? (email address required):

Yes

No

Please provide us with the name of your registered doctor and the GP surgery you are registered with.

GP Name:

GP Surgery:*

Do you have any physical difficulties or disabilities we may need to know about? (e.g. hearing problems, visual impairments, mobility issues):*

Yes

No

If yes, please state:

Please let us know if you have any of the following long term health conditions (tick all that apply):

Please let us know if you suffer from any of the following medically-unexplained symptoms (tick all that apply):

If you require any specific help to communicate with us (e.g. Interpreting, Braille, Large Font on your letters), please describe how we can assist you, including what language is needed if you require an interpreter:

Ethnicity:*

Religion:*

Sexual Orientation:*

Have you or a member of your family served in the UK Armed Forces?*

Please let us know if any of the following applies to you (select one or both if they apply):

I am pregnant

I am a mother with a child under 1 year of age

Where did you hear about our service?

If other, please specify:

If you can, please provide us with the information for an emergency contact. Please be aware that we will only contact this person in urgent circumstances.

Name of your Next-of-Kin (closest friend or family member):

Next-of-Kin's contact number:

Next-of-Kin's relationship to you:

Are there any days or times you cannot attend appointments? (Please note, although we will do our best to accommodate your availability, our normal working hours are 9:00am to 5:00pm and we only have a limited provision for evening appointments):

Would you be interested in receiving support to retain or gain employment in addition to your therapy?:*

Yes

No

Are you referring for support with or have experienced Post Covid symptoms or syndrome (also known as Long Covid)?:*

Yes

No

Once you have pressed the ‘Submit’ button, your information will be transferred to us securely and our administration team will complete the registration process. You will then be offered a telephone assessment appointment either by letter, telephone or online booking (link by text message). Depending on demand for the service, this offer of an appointment may take up to 10 working days to arrive.

At your assessment, you will have the chance to discuss your reasons for referring to our service and to find out more about what our service can do to support you.

If it is felt that our service is unable to offer you treatment at this time, we will endeavour to offer signposting to more suitable avenues of support.

Talking Mental Health Derbyshire is a partnership of several organisations: Derbyshire Healthcare NHS Foundation Trust, Derwent Rural Counselling Service, IESO, Relate and Xyla Digital Therapies. To help reduce the wait for our service, your referral for assessment may be passed to our digital therapy partner organisation Xyla. If you would prefer for your information not to be passed to Xyla please telephone 0300 123 0542 and advise our administration team.

For further detail about what information and data we collect and share please see: https://www.derbyshirehealthcareft.nhs.uk/services/talking-mental-health-derbyshire/interested-talking-therapy

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Self Referral Form

Please read before completing this form

About You

Your GP

Additional Information & Accessibility

Your Next-of-Kin

Your Treatment

Next Steps