Self Referral Form
Taking that first step towards seeking support for your mental health can be daunting, so thank you for taking the time to get to know ieso a little bit more and learn about the therapy services we have available. To refer to ieso, we would first like to ask you a few questions about yourself and how you are currently feeling. This referral form should take around 20 minutes to complete. You may be wondering why we ask these questions? This is so that our clinical team can assess, based on the information you provide, if ieso's service is a suitable treatment for the support you require.
If you have any queries, please contact our Patient Services Team on our freephone number: 0800 074 5560 or via email: info@iesohealth.com
Please be aware, if you feel at risk of harming yourself or at risk of harm from others, we may not be able to give you the level of support you need. Please contact these support numbers:
• Call 111 – if you are experiencing a mental health crisis and urgently require medical help or advice, but it is not a life-threatening situation.
• Call 999 – if you or anyone else is in immediate danger or harm.
• Call 116 123 – to speak to the Samaritans' helpline 24 hours a day.
To get started, please enter your basic details - this includes your full name, address and details of your GP. This should take around 5 minutes to complete.
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
Mx
First Name:*
Last Name:*
Date of Birth (DD/MM/YYYY):*
Gender (as you currently identify):*
Male
Female
Non-Binary
Other
Don't Know
Prefer not to say
Is your gender the same as assigned at birth?:*
Yes
No
Prefer Not to Say
Address Line 1:*
Address Line 2:
Town / City:*
County:
Postcode:*
Mobile Number:*
We use text messages to send you important information about your care, such as to enable you to schedule sessions and complete questionnaires. We will not use text messages to send marketing information.
Can we leave voicemail?:*
Yes
No
Email Address:*
Name of GP Surgery:*
Address of GP Surgery:*
ieso work alongside GP's to help keep all our patients safe, therefore, we will be sharing a high-level overview of your treatment with your GP at the start of your treatment and when you are discharged. This is standard practice throughout NHS services. If you have any queries, please contact our Patient Services Team.
In exceptional circumstances, if your clinician is concerned for your welfare or safety, or the welfare of another (child or adult), we have a legal duty to act and inform your GP. If you have any concerns about this, please speak to your clinician directly.
Do we have consent to refer you to your local service if you are not suitable for our service?:*
Yes
No
Great, thank you for filling in that information. Next, we need to go into a little bit more detail about yourself - including information about any current health conditions. This section will take around 5 minutes to complete.
Sexuality:*
Please Select A Value...
Heterosexual
Gay/Lesbian
Bisexual
Sexually attracted to neither male nor female sex
Unknown / Undecided
Other
Prefer not to Say
Ethnicity:*
Please Select A Value...
Asian or Asian British - Bangladeshi
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Any other Asian background
Black or Black British - African
Black or Black British - Caribbean
Black or Black British - Any other Black background
Mixed - White and Black African
Mixed - White and Black Caribbean
Mixed - Any other mixed background
Not known - Don't Know
Not Stated - Prefer Not to Say
Other Ethnic Groups - Arab
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
White - British
White - Irish
White - Any other White background
Religion:*
Please Select A Value...
Agnostic
Baha'i
Buddhist
Christian
Has religious belief
Hindu
Jain
Jewish
Muslim
Not religious
Other
Pagan
Prefer Not to Say
Sikh
Unknown
Zoroastrain
Have you served in the armed forces?:*
Please Select A Value...
Yes - ex services
No
Prefer Not to Say
Please give information on any disabilities (physical or learning), please tick all that apply to you:*
Behavioural and Emotional
Hearing
Learning (including memory, concentration and understanding)
Manual Dexterity
Mobility and Gross Motor
Other
Perception of physical danger
Personal, self care and continence
Progressive condition and physical health (e.g. HIV, cancer, multiple sclerosis, fits, etc)
Sight
Speech
No Perceived Disability
Prefer Not to Say
Please give information on any long term conditions, please tick all that apply to you:*
Asthma (of any kind)
Chronic Obstructive Lung/Pulmonary Disease
Chronic Pain, including fibromyalgia
Diabetes, including type 1, type 2, gestational
Disorder of digestive system
Disorder of musculoskeletal system, including rheumatism
Disorder of respiratory system
Disorder of Skin, including dermatitis and eczema
Heart Disease
Immune Disorder
Cancer of any type
Medically Unexplained Symptoms
Neurological Disorder, including dementia
None
Other
Prefer Not to Say
Please tick any of the below that apply to you (peri and post natal):*
Pregnant
Partner Pregnant
Has child/children under 2 years old
Has child/children between 2 and 18 years old
Previous mental health issues during pregnancy
None of the above
What is your current employment status:*
Please Select A Value...
Employed
Unemployed
Student
Retired
Homemaker or carer
Long term sick or disabled and receiving benefits
Not receiving benefits and not actively seeking work
Unpaid voluntary work
Not stated
How many hours do you work a week?:*
Please Select A Value...
30+ hours
16-29 hours
5-15 hours
1-4 hours
Not applicable
Not stated
Are you currently receiving statutory sick pay?:*
Yes
No
Unknown
Not stated
Are you currently receiving any benefits?:*
Yes
No
Unknown
Not stated
If yes, please select all that apply to you:
(Jobseeker’s Allowance (JSA)
Employment and Support Allowance (ESA)
Universal Credit (UC)
Personal Independence Pay (PIP)
Other
Are you currently taking any medication?:*
Prescribed and taking
Prescribed but not taking
Not prescribed
Unknown
Not stated
Where did you hear about us?:*
Please Select A Value...
GP
Health professional (midwife, health visitor, etc)
A mental health service other than ieso
myGP app
Social Media
Search Engine
Leaflet through the door
Newspaper/Magazine
Outdoor Poster (bus poster etc)
Radio
Word of Mouth
Other
Please copy the following links into your web browser to view:
• Privacy Notices - https://www.iesohealth.com/trustcentre/privacy-notices-nhs-patients
• T&Cs - https://www.iesohealth.com/trustcentre/terms-and-conditions-for-nhs-patients
I agree to the Terms and Conditions and acknowledge the Privacy Notice:*
Yes
We're nearly there, this is the final part of the referral form. In this section we would like to understand a little more about how you have been feeling recently and the symptoms that have been affecting you. This section will take around 10 minutes to complete.
PHQ 9 Questionnaire
Over the last 2 weeks, how often have you been bothered by the following problems:
1. Little interest or pleasure in doing things:*
0 = not at all
1 = several days
2 = more than half the days
3 = nearly every day
2. Feeling down, depressed or hopeless:*
0 = not at all
1 = several days
2 = more than half the days
3 = nearly every day
3. Trouble falling or staying asleep or sleeping too much:*
0 = not at all
1 = several days
2 = more than half the days
3 = nearly every day
4. Feeling tired or having little energy:*
0 = not at all
1 = several days
2 = more than half the days
3 = nearly every day
5. Poor appetite or overeating:*
0 = not at all
1 = several days
2 = more than half the days
3 = nearly every day
6. Feeling bad about yourself, or that you are a failure or have let yourself or your family down:*
0 = not at all
1 = several days
2 = more than half the days
3 = nearly every day
7. Trouble concentrating on things, such as reading the newspaper or watching television:*
0 = not at all
1 = several days
2 = more than half the days
3 = nearly every day
8. Moving or speaking so slowly that other people could have noticed or the opposite, being so fidgety or restless that you have been moving around a lot more than usual:*
0 = not at all
1 = several days
2 = more than half the days
3 = nearly every day
9. Thoughts that you would be better off dead, or of hurting yourself:*
0 = not at all
1 = several days
2 = more than half the days
3 = nearly every day
GAD7 Questionnaire
Over the last 2 weeks, how often have you been bothered by the following problems:
1. Feeling nervous, anxious or on edge:*
0 = not at all
1 = several days
2 = more than half the days
3 = nearly every day
2. Not being able to stop or control worrying:*
0 = not at all
1 = several days
2 = more than half the days
3 = nearly every day
3. Worrying too much about different things:*
0 = not at all
1 = several days
2 = more than half the days
3 = nearly every day
4. Trouble relaxing:*
0 = not at all
1 = several days
2 = more than half the days
3 = nearly every day
5. Being so restless that it is hard to sit still:*
0 = not at all
1 = several days
2 = more than half the days
3 = nearly every day
6. Becoming easily annoyed or irritable:*
0 = not at all
1 = several days
2 = more than half the days
3 = nearly every day
7. Feeling afraid, as if something awful might happen:*
0 = not at all
1 = several days
2 = more than half the days
3 = nearly every day
Self-Assessment Questionnaire
Which of the below best describes the main problem you are looking for support with?:*
Please Select A Value...
Anxiety, worry or stress
Bereavement
Distressing Event
Low mood/depression
Obsessive Compulsive Disorder (OCD)
Other
Phobia
Relationship Difficulties
Sleep Problems
Worries about health
Worries about social situations
Please tell us about this problem; What are the main symptoms that you struggle with? How do the problems make you feel? Is there a recent example that would help you explain?:*
How does what you’ve described impact on your daily life? Does it impact your work or hobbies, on your friendships, relationships or family life?:*
How long has this been gong on for?:*
Less than 6 months
6 months to 2 years
On and off for more than 2 years
More than 2 years
Is there anything that has happened recently or in the past that may have contributed to these problems developing? Are there any particular triggers, such as certain situations or life events?:*
Using alcohol and drugs can affect mental health, please let us know if you use any of the following so it can inform your treatment:*
Alcohol (more than 14 units per week)
Illegal substances/drugs
None of these
If you selected use of either alcohol or illegal substance/drugs, please provide further details:
If ‘no’, please put N/A in the box and move to the next question.
Have you had any therapy or counselling in the past? What type of therapy was this? Was it helpful? When did this take place?:*
Do you have a current or previous mental health diagnosis? If yes, please provide more details:*
Are you prescribed any medication for a mental health difficulty? If yes, which medication(s) are you prescribed and are you still taking them?:*
Are you currently receiving any professional support from other services? For example, for your mental health, physical health or social services? If yes, please provide details:*
Please tell us what you are hoping to gain from the service. What would your goals for therapy be:*
Is there anything else you would like us to know that you feel would be helpful? If yes, please provide details:*
Thank you for spending time answering the questions, we appreciate there were quite a few to answer.
What happens next?
Once you click the 'submit' button, our team will receive your form and will check your responses to make sure ieso is a suitable service for the support you require. If it is, you will receive an email link to activate your account on the ieso therapy site. Keep an eye out for an SMS as the link to book your first therapy session with one of our fully qualified clinicians will be sent via text.
We wish you the very best for your therapy journey with ieso.
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