Referral Form

Referrer Details

Referrer name:*

Job Title of Referrer:*

Referrer organisation:*

Contact e-mail address:*

Contact phone number:*

Title:*

First Name:*

Last Name:*

Date of Birth:*

Gender:*

Is gender the same as that assigned at birth?:*

Yes

No

Preferred Pronouns:*

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Home Phone Number:

Permission to leave voicemail on landline?:

Yes

No

Mobile Phone Number:

Permission to Leave Voicemail on mobile?:

Yes

No

Permission to send SMS Text reminders?:

Yes

No

Email Address:

Please note, we can only accept referrals for patients registered with a GP in Thurrock.

GP Surgery:*

GP Name:

Emergency Contact Name:*

Emergency Contact Phone Number:*

Nationality:*

Ethnicity:*

Religion:*

Is the patient able to communicate in English?:*

Yes

No

Unknown

Do they need an interpreter?:*

Yes

No

Preferred Language:

Relationship Status:*

Sexuality:*

Does the patient have any disabilities or special access requirements? e.g. visual impairment, hearing difficulties, mobility issues:

Yes

No

Unknown

If yes, please specify:

Any Long Term Conditions? (e.g. cancer, diabetes, heart disease, stroke):*

Yes

No

Unknown

If yes, please specify:

Are they ex-British Armed Forces?:*

Are they a Carer?:*

Yes

No

Not Stated

If yes, what does the person they care for suffer with?:

Reason for referral (please give a full and complete reason for referral, including existing and historic mental health diagnoses, interventions already tried and response to these):*

Do these difficulties impact on their employment/ability to work?:*

Yes

No

Are they seeing any other therapists?:*

Yes

No

Current or past RISK to self or others, safeguarding issues. Please give full details:

Please complete the captcha

Health Professional Referral Form

Referrer Details

Patient Details

GP Details

Emergency Contact Details

Further Details

Referral Reason