Referral Form

Please note, NHS Coventry, Warwickshire and Solihull Talking Therapies Service 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 Wellbeing Line 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.

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:*

Gender:*

Male

Female

Not specified

Not known

How would you describe your sexual orientation?:*

What is your ethnicity?:*

Email address:

We will use your email to communicate important information about our service, such as appointment times and questionnaires to be completed prior to your appointments. We do not use your email address for any other purpose and never sell your information to any third party.

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

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

Yes

No

Please provide at least one contact number.

Home Phone Number:

Is it ok to leave a voicemail on this number and say it is NHS Talking Therapies?:

Yes

No

Mobile Phone Number:

Can we send you text message reminders for appointments?:

Yes

No

Is it ok to leave a voicemail on this number and say it is NHS Talking Therapies?:

Yes

No

NHS Number (if known):

GP name (if known):

GP Practice:*

Are you able to communicate in spoken and written English?

If you are unable to communicate in English please state your preferred language:

Please describe the problems that you are experiencing that you would like us to help with:*

Do you have a long-term physical health condition?

Are you or your partner expecting a baby or do you have a child under 12 months old?

Where did you hear about the service?:

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

Yes

No

Thank you very much for completing these questions. If you have given permission for us to contact you via text message, then you will receive a booking link via text message within 7 working days. If you have not agreed to contact via text message, then we will make contact via either email or letter advising you how to book you initial appointment. If you do not hear from us within the next 14 days, or you need to contact us for any other reason then please call 02476 671 090.

Please complete the captcha

Self Referral Form

Personal Information

Reasons for referral

What happens next?