Referral Form

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.

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.

Title

First Name

Last/Family Name

Date of Birth

Gender Identity

Male (including transgender male)

Female (including transgender female)

Non-binary

Not specified

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

Sexuality

Are you pregnant or do you have a child under 12 months old?

Yes

No

Are you happy to be contacted for research purposes?

Yes

No

Not sure

Are you registered with a GP in Lambeth?

Yes

No

If yes, please select your Lambeth GP practice from the drop-down menu

If no, please add the name of your GP practice

Are you an NHS or Social Care worker?

NHS

Social Care

N/A

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 hear about Lambeth Talking Therapies?

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.

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.

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.

We offer a digital programme based on CBT principles aimed at helping you to reduce symptoms of depression, anxiety or stress. You can log in at any time and will have weekly reviews with a therapist.

If you are interested in this option, please indicate it here:

I am interested in computerised CBT

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.

We anonymously share data from our service with NHS England and other statutory bodies that monitor our performance. This information may include number of people we see, what type of treatment they receive, or if they recovered. This does not include personally identifying information such as your name, address, contact details, etc. If you wish to opt out of NHS data sharing please copy and paste the following link to a new web browser https://www.nhs.uk/using-the-nhs/about-the-nhs/opt-out-of-sharing-your-health-records/

Please complete the captcha

Self Referral Form

Personal Details

GP Details

How did you find us?

What is the problem?

Extra Information

Booking Your Appointment

Are you interested in computerised CBT?