Referral Form

Refer yourself

Talking Therapies is for everyone aged sixteen or over, who live in Portsmouth and are registered with a GP in the city.

You can self-refer to Talking Therapies by completing this secure form. The form takes up to 10 minutes to complete.

Please do not fill in this form on behalf of someone else unless you have permission to do so.

If you are a health or social care professional wishing to make an online referral on behalf of someone, please use the assisted referral form.

Are you in crisis, feel you may seriously harm yourself, or need immediate help?:*

Yes

No

If you selected Yes, we’re sorry we are unable to accept a referral from you at the moment. Please visit the ‘Urgent help’ section of our website for guidance.

Are you aged sixteen or over?:*

Yes

No

If you selected No, we’re sorry we are unable to accept a referral from you at the moment. Please contact your GP to discuss local services for children and young people.

Are you currently living in Portsmouth, and registered with a GP in the city?:*

Yes

No

If you selected No, we’re sorry we are unable to accept a referral from you at the moment. Please visit the ‘Refer’ section of our website for help finding your local service.

Are you currently receiving, or about to receive, therapy or mental health care from a different service?:*

Yes

No

If you selected Yes, we’re sorry we are unable to accept a referral from you at the moment. If you need clarification, please contact us on 0300 123 3934.

Do you have a physical health condition?:*

Yes

No

If yes, please specify:

If other, please specify:

Alongside therapy we can also assist you finding employment or training, and help you with workplace adjustments or disputes. Would you like support?:*

Yes

No

Title:*

First name:*

Last name:*

At birth were you described as…:*

Male

Female

Intersex

Prefer not to say

Which of the following describes how you think of yourself now?:*

Male

Female

In another way

Prefer not to say

If in another way, please specify:

What are your preferred pronouns?:*

he/him

she/her

they/them

other

If other, please specify:

Date of Birth:*

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

We’d like to keep you updated about your care at every step.

Mobile phone number:

May we leave you a voice message?

Yes

No

May we send you a text message?:

Yes

No

Home phone number:

May we leave you a voice message?:

Yes

No

We will ask you to complete questionnaires before each appointment to help us understand how you’re feeling. You may prefer to complete them online to save time. May we email you with a secure link?:*

Yes

No

May we email you about your care, containing personal identifiable information?:*

Yes

No

May we email you with therapy materials?:*

Yes

No

Email address:

The NHS uses an encryption feature for all emails to correspond securely.

In the event of an emergency, please provide the details of someone who we can contact – ideally someone who lives nearby you.

First name:

Last name:

Phone number:

We ask these next questions to make sure we’re doing our best by reaching out to everyone in the community.

What is your ethnic group?:*

What is your religion?:*

What is your sexual orientation?:*

We keep you informed about your appointments and care, and copies of these communications are sent to your GP to keep them updated.

Please select the name of the GP practice where you’re registered:*

We support people with a wide range of needs, and we’d like to be as helpful as possible.

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

Are you related to a serving member or a veteran of the British Armed Forces?:*

Yes - currently serving member

Yes - Veteran

No

Are you or your partner pregnant?:*

Yes

No

Do you have a baby under the age of 24 months?:*

Yes

No

Would you like someone to provide sign language?:*

Yes

No

If yes, please specify:

British Sign Language

Makaton

Would you like a language interpreter?:*

Yes

No

If yes, please specify which language:

Do you require easy read material?:*

Yes

No

Would you prefer to read things in large print?:*

Yes

No

Would you prefer to receive online therapy?:*

Yes

No

Do you need help with weight management?:*

Yes

No

Do you need help with sleep?:*

Yes

No

Talking Therapies and Solent NHS Trust safely manage and share the information collected about you, in compliance with the Data Protection Act (2018) and the General Data Protection Regulation (2016).

We keep the information that you share with us on a dedicated computer system to ensure that it is stored safely. Your information may also be accessed securely by other mental health services within Solent NHS Trust to plan and monitor your care. We may also want to share information with other professionals who need to be involved in your care, and in this event we will ask for your permission beforehand. We may need to share information with other professionals without your permission if we are concerned about your safety, the safety of another person, or you inform us that you have/or are about to commit a serious crime. Should this be the case we will discuss this with you first and involve you in the process if possible.

We will provide your GP with a copy of the letters that we send to you to keep your medical records updated, and we are required to send a limited amount of information relating to your care to NHS Digital who will remove your identifying details and use it to assist in the monitoring and the commissioning of mental health services in England.

We are proud to be an organisation that promotes and supports clinical research, whilst maintaining confidentiality. Our ‘Count Me In’ initiative means that if there is a research study or service improvement project we think you might be interested in, we will contact you to see if you would like to be involved. More information about the initiative can be found by visiting: www.academy.solent.nhs.uk/research/count-me-in

If you have any questions about this policy - if you do not wish for your information to be shared with your GP, other mental health services or NHS Digital, or if you wish to opt out of the ‘Count Me In’ initiative - please contact us on 0300 123 3934.

I have read, understood, and agree to the data policy:

Please select:*

Yes

No

If you selected No, please contact us on 0300 123 3934 before submitting your referral.

We’d like to share our latest news with you by email – we provide updates about our therapies, our community projects, and our free wellbeing workshops across Portsmouth.

Would you like to receive our newsletter?:*

Yes

No

Talking Therapies uses Sendinblue to email our newsletters. Sendinblue will be responsible for storing and managing your name and email address. You can unsubscribe and remove your details at any time. Please visit the ‘Policies’ section of our website for further information.

Where did you hear about Talking Therapies?:*

If other, please specify:

Carefully review your information before submitting your referral. When you’re ready, click on the ‘Submit’ button below. We’ll let you know that we’ve received your information securely.

Please complete the captcha

Self Referral Form

Refer yourself

May we first check…

How may we help you?

Tell us about you

How may we contact you?

Emergency contact

Additional details

Your GP practice

How else could we help?

Data policy

The final bit…

Review your information