Referral Form

Patient Information

NHS Number (If known)

Title*

First Name*

Last Name*

Date of Birth*

Gender*

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

If Other is selected, please specify

GP Name*

GP Practice & Address*

GP Telephone Number*

Please only complete this section if the referrer is NOT a GP. (If GP practice leave blank)

Name

Profession

Service

Contact Number

Email

(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?

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Health Professional Referral Form

Patient Information

GP Details

Referrer Details

Referral Information