Referral Form

Please answer each question as fully as possible.

By submitting this form you are consenting to us sharing information with your GP.

Title:*

First Name:*

Last Name:*

Date of Birth:*

You must be over 16 to access this service, if under 16 please speak to your GP.

Email address:

(Please only provide if you give permission for us to email information about your care and any online forms that you may require as part of your treatment)

Are you willing to be contacted to participate in research?:*

Yes

No

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Are you happy for us to send post to this address?:*

Yes

No

Gender:*

Male

Female

Not specified

Not known

Home Phone Number:

Mobile Phone Number:

Please provide us with at least one contact number.

NHS Number:

GP name (if known):

GP Practice:*

Can we send you text message reminders for appointments?:

Yes

No

Is it ok to leave a message on your voicemail and say it is Coventry, Warwickshire and Solihull Healthy Mind Service (IAPT) ?:

Yes

No

Would you like to give us permission to talk to anyone else about your care?:*

Yes

No

If Yes, what is the name of the person, their relationship to you and their contact number?:

Are you currently in education?:*

Yes

No

If Yes please provide details of the educational establishment that you are attending:

Are you a Refugee/Asylum Seeker?:*

Yes

No

What is your ethnicity?:*

What is your religion?:

Is English your main language?:

Yes

No

Unknown

Do you need an interpreter?:

Yes

No

What is your preferred language?:

Do you have a disability?:*

Yes

No

Unknown

If Yes, please specify:

If you have a long term physical health condition, please specify the nature of this below:

Are you a member or ex-member of the British Armed Forces?:*

Do you have any special requirements?:

How would you describe your sexual orientation?:*

What is your marital status?:*

Are you struggling with stress, depression, low mood or anxiety?:*

Yes

No

Are you or your partner expecting a baby?:*

Yes

No

Do you or your partner have a child under 12 months old?:*

Yes

No

Have you currently been prescribed any medication for your mental health?:*

Yes

No

Don't know

If so, what have you been prescribed and since when?:

Do you find yourself using alcohol or taking recreational drugs to help you cope with your problems?:*

Yes

No

If Yes, please tell us more:

Have you had previous contact with mental health services, or therapy/counselling?:*

Yes

No

If Yes, please give the details of these and dates if possible:

Is there anything else we should know before we make any appointments for you?:

Where did you hear about the service?:

Please note, Coventry, Warwickshire and Solihull Healthy Mind Service (IAPT) is not a crisis service. If you are currently experiencing distressing thoughts and feel you may be at risk of harming yourself or someone else, please contact one of the following:

Your GP or out-of-hours service / NHS Direct on 111 / The Samaritans on 116 123, Mental Health Matters on 0800 616171 (Coventry and Warwickshire only) The Mental Health Access Hub on 0300 200 0011 (Coventry and Warwickshire only), Birmingham and Solihull Urgent Mental Health Helpline on 0121 262 3555 or 0800 9159292 (Solihull only). In an emergency dial 999 or visit A&E.

Thank you very much for completing these questions. We will contact you once we have reviewed this form.

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Self Referral Form

Personal Information

Reasons for referral

What happens next?