Health Professional Referral Form
Patient Information
NHS Number (If known)
Title*
Please Select A Value...
Mr
Mrs
Miss
Ms
Mx
Dr
Rev
Prof
First Name*
Last Name*
Date of Birth*
Gender*
Male
Female
Other
Not Known
Not specified
If 'other' is selected, please specify
Address Line 1*
Address Line 2
Town/City*
County*
Postcode*
Permission to send written communication to patient’s home address?
Yes
No
Mobile Number*
Permission to send text?
Yes
No
Permission to leave voicemail?
Yes
No
Home Phone Number
Email
Permission to contact by Email?
Yes
No
Does the patient require an interpreter / translator?*
Yes
No
If Yes is selected, please specify the language
Please Select A Value...
Akan (Ashanti)
Albanian
Amharic
Arabic
Bengali & Dhaka
Bengali & Sylheti
Brawa & Somali
British Signing Language
Cantonese
Cantonese and Vietnamese
Creole
Dutch
English
Ethiopian
Farsi (Persian)
Finnish
Flemish
French
French creole
Gaelic
German
Greek
Gujarati
Hakka
Hausa
Hebrew
Hindi
Igbo (Ibo)
Italian
Japanese
Korean
Kurdish
Lingala
Lithuanian
Luganda
Makaton (sign language)
Malayalam
Mandarin
Norwegian
Pashto (Pushtoo)
Patois
Polish
Portuguese
Punjabi
Romanian
Russian
Serbian/Croatian
Sinhala
Somali
Spanish
Swahili
Swedish
Sylheti
Tagalog (Filipino)
Tamil
Thai
Tigrinya
Turkish
Urdu
Vietnamese
Welsh
Yoruba
Other
If Other is selected, please specify
GP Details
GP Name*
GP Practice & Address*
GP Telephone Number*
Referrer Details
Please only complete this section if the referrer is NOT a GP. (If GP practice leave blank)
Name
Profession
Service
Contact Number
Email
Referral Information
(Please feel free to provide any further information using the space below)
List of significant diagnosis
Identified problems and what would you like us to provide? (If possible, we would be grateful if you could include history of your patient’s difficulties, duration & diagnosis)
Has this referral been discussed with patient?
Yes
No
What does the patient hope to get out of a referral to Talking Therapy? E.g. feeling better, less depressed.
Is there any immediate concern about risk to self or others which require urgent attention?
Yes
No
If Yes – Do not proceed with this referral. Please visit the Emergency section of our website to get information on how to refer to The Crisis Hub.
If no, are there other concerns regarding risk to self or others we should be aware of?
Alcohol/substance misuse?
Yes
No
If yes, please provide more information.
If Alcohol and substance misuse are the primary problem, please visit the CGL website. You can find information about CGL on our website in the Resources section.
Please specify if the patient has a primary problem of:
Diabetes
COPD
Other Long Term Health Condition
Other, please specify below
If other, please specify
Is your patient currently under the care of Psychiatric or any other specialist team for their psychological problems?
Yes
No
If yes, please specify
Any relevant/important information you think would be helpful for us to know?
Please complete the captcha
Submit
Cancel