Referral Form

NHS West Sussex Talking Therapies is not a crisis service and we are not able to provide crisis support. If you are in crisis and need urgent support, please do not fill this form in and instead contact one of the following services:

• The Samaritans: 116 123 (24hrs)

• NHS 111 and select the mental health option to be connected to a 24/7 mental health crisis line.

• Text SUSSEX to 85258. This free, confidential, anonymous text support service is available 24/7 and is run by trained volunteers.

• Your local A&E department

• Stay Alive App (www.stayalive.app)

• Your GP, and request an urgent appointment

Our qualified approachable team offer talking therapies to you alongside your healthcare team to achieve the outcomes you want. This form allows you to refer yourself to the service. If you have any problems completing it or have additional needs that you would like us to know about then please contact our admin team on the contact number below who will be very happy to help you complete your referral over the telephone. Please call us on: 01273 666480

Are you completing this form for yourself? (i.e. not on behalf of someone else)*

Yes

You cannot fill in this form on behalf of someone else. This form is not, however, the only way to access the service. You can call on the phone numbers listed above or can be referred via your GP.

The following section collects your personal information. All information is kept securely in accordance with the Data Protection Act and General Data Protection Regulation (GDPR) and is shared only with healthcare professionals in relation to your treatment. For more about how we use your data please see our privacy policy: https://westsussextalkingtherapies.nhs.uk/privacy-policy

After you submit this form you will be contacted within three working days to arrange an assessment with a therapist. This assessment will take 45-60 minutes and will help us clarify your needs and determine whether this is the best service for you. PLEASE BE AWARE THAT WHEN WE CALL YOU OUR TELEPHONE NUMBER WILL SHOW AS “WITHHELD” ON YOUR PHONE.

Are you 18 or over?*

Yes

We are an adult service and do not treat people under 18 years old. If you are under 18 and wish to access talking therapy you can self-refer on the e-wellbeing website (e-wellbeing.co.uk/support) or make an appointment with your GP to discuss the available options.

Do you live in West Sussex?*

Yes

If this is not the case, you can find your local talking therapy service by visiting the NHS Choices website at www.nhs.uk. If you would prefer to be seen by us, please contact the phone number above to discuss your referral.

Are you registered with a GP practice in West Sussex?*

Yes

If this is not the case you can find your local talking therapy service by visiting the NHS Choices website at www.nhs.uk. If you would prefer (or still like) to be seen by us, please contact the phone number above to discuss your referral.

Will you be available for a 45-60 minute assessment in the next six weeks?*

Yes

We will aim to offer an assessment within a few weeks and ask that you are available for this within the next six weeks of making this referral. If you will be unavailable for assessment within the next six weeks, we would ask you to refer at a time when you are available. Please note we are not a crisis service.

I agree that NHS West Sussex Talking Therapies will share information with my GP or obtain information from them if needed*

Yes

If you would like more information on this, please call 01273 666480.

I agree that NHS West Sussex Talking Therapies may access my health records from secondary care mental health services e.g. the ATS (Assessment and Treatment Service) or Specialist Perinatal Mental Health Service, where the sharing of information would support my best care.*

Yes

If you would like more information about this please call 01273 666480.

If you answered “Yes” to all of the above, please complete all fields on the form below to access the Time To Talk service. If you’re unable to answer “Yes” to any of the above and would still like to access the service, please call us on the number above to discuss.

Title:*

First Name:*

Surname:*

What are your pronouns? (e.g. she/her, he/him, he/they etc.)

Gender:*

Are you pregnant or have a child under the age of 12 months?*

Yes

No

Date of Birth:*

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Mobile Number:*

We need a mobile number in order for you to self-refer online. If you cannot provide a mobile number we can still register you over the phone - please ring us using the contact details at the top of this form to self-refer. If you consent to us sending you text messages in the question below, we can send out a booking link so you can book your initial assessment online quickly. If you don't consent to us sending text messages, we will ring you to book in your initial assessment.

Can we leave messages on this number?*

Yes

No

Can we send you SMS text reminders?*

Yes

No

Email Address:*

Confirm Email Address:*

I consent to all correspondence about my treatment being sent by email:*

Yes

We need an email address in order for you to self-refer online. If you cannot provide an email address we can still register you over the phone - please ring us using the contact details at the top of this form to self-refer. To find out about the way we send emails view our privacy policy https://westsussextalkingtherapies.nhs.uk/privacy-policy

Are you a veteran of the armed forces?

If you need a language interpreter for appointments (including British Sign Language) please indicate the language required:

Are you currently receiving help from another mental health service or specialist service (e.g. drug/alcohol service)?:

Yes

No

If yes please state which service:

Have you received help from another mental health or specialist service (e.g. drug/alcohol service) in the past?:

Yes

No

If yes please state which service and when you last had contact with them:

Do you have any of the following long term health conditions?:

If you have been diagnosed with one of the above conditions, is your condition directly contributing to your stress levels, anxiety or low mood?:

Yes

No

On receipt of your details we will contact you to make an appointment for assessment. If we're unable to meet your needs please be assured we'll advise you and let you know of suitable alternative help available.

Do you have any disabilities that require any adjustments to the way we communicate or work with you?:

Yes

No

Do you consider yourself to be neurodiverse? (this includes people with autism, ASD and ADHD):

Yes

No

Do you require any adjustments to the way we communicate with you?:

Yes

No

If yes to any of the above, let us know details here. We will try our best to accommodate:

Equalities and montioring

It is helpful if we know some further information about you for national reporting. It is not mandatory to answer the questions below. If you do not want to answer a question, please select ‘prefer not to say’ but if you do, this data will be anonymous and will not be viewed by anyone within our service. For more about how we process this date please see our privacy policy. https://westsussextalkingtherapies.nhs.uk/privacy-policy

Is your gender the same as that assigned at birth?

Ethnicity:*

Sexuality:*

Relationship Status:*

Religion:*

How did you hear about NHS West Sussex Talking Therapies?

I have read the privacy policy and understand how the service will use my data:*

Yes

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NHS West Sussex Talking Therapies

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