Referral Form

Patients Details

NHS Number, if known

Title*

First Name*

Last Name*

Gender*

If 'other' is selected, please specify

Date of Birth*

We do not accept referrals that are under the age of 18. Please visit the Resources section of our website to find information for Under 18s Support.

Address Line 1*

Address Line 2

Town/City*

County*

Postcode*

Permission to send written communication to your home?*

Yes

No

Mobile Phone Number*

Permission to send text*

Yes

No

Permission to leave voicemail*

Yes

No

Please note that Newham Talking Therapies will be calling from a withheld/private number. We will only leave a message if you have given us permission to do so.

Home Phone Number

Email*

Permission to contact by email?*

Yes

No

Please share the details of someone we can contact in the event of an emergency. We would only ever contact this individual where we have concerns about yourself in order to help you find the correct immediate support and this is a requirement to be seen within our service.

First Name*

Last Name*

You must provide a UK number.

Telephone*

Relationship*

National Identity

Ethnicity

Religion

Able to communicate in spoken English?

Yes

No

Understands written English?

Yes

No

Do you require an interpreter / translator?*

Yes

No

If Yes, please specify which language

Relationship Status

Sexual Orientation

Disability Status

Long Term Condition Status

Newham Talking Therapies offers employment support alongside therapy, this can be to help find work or remain in work. Is this something you would be interested in?*

Yes

No

GP Practice*

By referring yourself to this service you are agreeing that the service may contact and share relevant information with your GP to facilitate your care

We are always looking to enhance our service for future service users. Once you have completed your treatment would you consent for us to contact you by telephone and email to understand your experience of using our service?

Yes

No

We work with Xyla Digital Therapies and ERIS (East London NHS Foundation Trust Remote IAPT service) to ensure we can offer assessments/treatments to residents as soon as possible. It could be that your assessment/treatment is delivered by these partners and by referring you are agreeing to your data being shared with them in order to deliver your assessment/treatment. Our partners follow our own data protection and confidentiality policies.

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Self Referral Form

Patients Details

Address

Contact Details

Emergency Contact Details

Demographics

Registered GP Details