Referral Form

To refer yourself to Living Well Consortium’s online CBT service (cCBT), please fill in the form below. Within 30 minutes of this form being submitted, Silvercloud will email you to complete secondary questionnaires around your general wellbeing. These must be completed for your referral to be processed.

For more information on cCBT, please look on our website under Urgent Help and Referrals. If you are not looking to access cCBT, information on our other services can be found on the same page.

If you have any issues completing this form, please give us a call on 0121 663 1217 between 9 and 5pm, Monday to Thursday, or 9 and 4pm on Friday.

Please be aware that our service is not a crisis service. If you are feeling suicidal, please contact your GP for an emergency appointment, call the Birmingham Mind 24 hour line on 0121 262 3555 (freephone 0800 915 9292), the Samaritans on 116 123 or attend your local A&E.

This referral form is for assessment and access to SilverCloud Computerised Cognitive Behavioural Therapy (cCBT) only. This is considered by Living Well Consortium to be a treatment intervention in its own right. Whilst your referral for SilverCloud is active, you may not:

• Be on any assessment or treatment waiting list with Living Well Consortium

• Be currently accessing any other treatment with Living Well Consortium

• Have accessed any other treatment with Living Well Consortium within the last 3 months

If you complete this form whilst any of the above conditions apply, you may be contacted via telephone or email for clarification.

Before we start, do you consent to us storing your data? If not, we cannot take your referral at this time.*

Yes

Title:*

First Name:*

Last Name:*

NHS Number:

Gender:*

Male (including Trans Man)

Female (including Trans Women)

Other not listed

Is your gender identity the same as assigned at birth?:*

Yes

No

I’d rather not say

Preferred Pronouns:*

Sexuality:*

Ethnicity:*

Date of Birth:*

Address Line 1:*

Address Line 2:

Town/City:*

Postcode:*

Have you (or do you depend on someone who has) served in the British military?:*

Do you have any disabilities we should be aware of?:*

Do you have a long-term condition?:*

Yes

No

I’d rather not say

If yes, please select from the following:

If other please give details:

Do you feel your physical health is currently impacting your mental health?:

Yes

No

Are you or your partner currently pregnant, or do you have a child under 1?:*

Yes – I am/My Partner is pregnant

Yes – I have a child under 1

No

Are you currently taking any prescribed medication for your mental health?:*

Yes

No

If yes, what medication are you taking?:

Are you currently using non-prescribed drugs or alcohol to manage your mental health?:*

Yes

No

Unsure

To access our service you must be registered with a GP in Birmingham or Solihull. Which GP are you currently registered with?:*

Please provide a valid phone number, either mobile or landline.

Mobile Number:

Permission to leave voicemail:

No

Yes

Permission to contact by SMS

No

Yes

Home Number:

Permission to leave voicemail:

No

Yes

Email:*

Can we email you?:*

Yes

No

Do you need an interpreter?:*

Yes

No

If yes, for which language?:

Do you require any adjustments or have other difficulties that would affect communicating with us?:

Next of Kin Name:*

Next of Kin Phone Number:*

Next of Kin Relationship to Client:*

What's the main issue you are looking for support with?:*

(Please try to describe your thoughts, feelings, things that trouble you, and the impact this is having on your life in a few sentences.)

And what would you like to achieve from therapy? If you are currently unsure, feel free to skip this:

Do you feel you would benefit from employment advice?:*

Yes

No

Unsure

Where did you hear about us?:*

Please complete the captcha

Self Referral Form

About You

Your Health

GP Details

Contact Details

Next of Kin Details

How can we help?