Self Referral Form
V2
V2
To refer yourself to our service simply fill in the form, let us know when you are available and we will send you an appointment.
We have included some optional extra questions at the end which could make your phone appointment shorter, please fill these out if you want to.
Please be aware that our service is not a crisis service and if you are in a suicidal crisis, please contact your GP for an emergency appointment, call the Samaritans on 116 123 or attend your local A&E.
Personal Details
Title
Please Select a Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
First Name
Last/Family Name
Date of Birth
Gender
Male
Female
Other
Address Line 1
Address Line 2
Town/City
Postcode
Permission to send letters to your home address
Yes
No
Mobile Number
Permission to contact by text
Yes
No
Permission to leave voicemail
Yes
No
Other Number
Permission to leave voicemail
Yes
No
E-mail
Permission to send email?
Yes
No
Do you need an interpreter?
Yes
No
If yes, please specify your language
Ethnicity
Please Select a Value...
White British
White Irish
White Other
White and Black Caribbean
White and Black African
White and Asian
Other Mixed Background
Indian
Pakistani
Bangladeshi
Asian Other
Black Caribbean
Black African
Black Other
Chinese
Other Ethnic Background
Do not wish to state
Sexuality
Heterosexual
Gay/Lesbian
Bisexual
Other
Do not wish to say
Are you pregnant or do you have a child under 12 months old?
Yes
No
Where have you lived for the past 12 months?
In the UK
Elsewhere
If elsewhere, please state
We anonymously share all the data from our service with the Department of Health, however there is no way that an individual can be identified. Please tick to consent here.
Yes
Unsure - please discuss with me in my phone call.
Are you happy to be contacted for research purposes?
Yes
No
Not sure
GP Details
Are you registered with a GP in Lambeth?
Yes
No
Do you work for the NHS? (e.g. an NHS Trust, primary care, or a charity funded by primary care, CCG.)
Yes
No
Do you work in Social Care? (e.g you work for the local authority, in a care home, or providing care for residents at home)
Yes
No
We will not be able to accept or process your referral if you are not registered with a Lambeth GP. (We do accept referrals for Health and Social care workers who are not registered with a Lambeth GP)
GP Practice
Permission to inform GP of referral and outcome of referral
Yes
No
Please note we always share information about risk with GPs. Even if you tick no here, any risk concerns will be shared with your GP.
How did you find us?
How did you hear about Lambeth Talking Therapies?
Please Select A Value...
My GP told me
The hospital
Another healthcare professional
Voluntary organisation
The NHS Choices website
Online search
Social media
From a family member, friend or colleague
I've used Lambeth Talking Therapies before
Other
What is the problem?
Please tell us your reason for seeking talking therapy
If you are looking for a different kind of help, such as with help with housing or debt problems, please look at our resource page on our website.
Extra Information
Do you have any disabilities we need to know of?
Yes
No
Do you require any adjustments or have other difficulties that would affect communicating with us?
Yes
No
If yes to any of the above, let us know how best to contact you and we will try our best to accommodate.
Booking Your Appointment
The next step is we will call you for a telephone assessment, which will take about 20-30 minutes, to find out more about your difficulties and discuss next steps.
We will text you a time for this phone call. This will usually be within the next week, and assessments are available Monday - Friday, between 9.15 and 4pm.
Please specify below what days and times you are available for this call in the next week (or suggest other days if more convenient) e.g. Tuesday 10-11, Friday 9-3.30pm, or 'Monday' or 'anytime'. Please offer as many times as you can.
(If you would prefer to call us to arrange this, please call us on 0203 228 6747).
Days and times in the next week when you are free for a call:
We will then text you an appointment time as soon as possible. Please check your phone daily.
Thank you for contacting us. We look forwards to speaking with you. You will next hear from us via text to tell you about your appointment.
IF YOU WOULD LIKE TO GIVE US SOME EXTRA INFORMATION THAT CAN MAKE YOUR TELEPHONE CALL QUICKER, PLEASE DO SO BELOW. THESE ARE ENTIRELY OPTIONAL.
Are you interested in online therapy?
We offer an online programme to offer flexible and easy to access therapy.
Here is a video link for more information. Please copy and paste it into a new web browser to view it. https://vimeo.com/348176560
If you are interested in this option, please indicated it here and let us know when you call
I am interested in online therapy
I am not interested in online therapy
Please tell us a little more about your main difficulties
How long have you felt this way?
What impact does this have on you and your life? For example, on your work or relationships.
Have you found anything so far that helps?
Have you had therapy before? Was it useful?
What led to you seeking help now?
If you were feeling better, how would life look different now?
Please complete the captcha
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