Self Referral Form
IAPT is not a crisis service.
If you need urgent support, please do not complete this form. If you feel unable to keep yourself (or others) safe and need immediate help, CALL 999 or go to the nearest hospital A&E Department.
Alternatively, please call:
- Oxleas Urgent Advice Line on 0800 330 8590
- The Samaritans on 116 123 (available 24 hours, free to call from landlines and mobiles)
- The NHS non-emergency service on 111 who can advise you if you are unsure of what to do
Please complete all questions below - Your referral may not be processed until all the necessary information has been received.
YOUR DETAILS
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
First Name:*
Surname:*
Date of Birth:*
Gender:*
Male
Female
Not known
Not specified
Address Line 1:*
Address Line 2:
Town/City:*
County:*
Postcode:*
Landline Number:
Can we leave a voicemail on this number?:
Yes
No
Mobile Number:
Can we leave a voicemail on this number?:
Yes
No
Can we contact you by SMS?:
Yes
No
Email:*
Please write your email address again:*
GP Name and Practice:*
NHS Number:
Are you currently pregnant?:
Yes
No
Is your partner currently pregnant?:
Yes
No
Are you a parent of a baby under 12 months?:
Yes
No
PHQ-9
Over the last 2 weeks, how often have you been bothered by any of the following problems?
1) Having little interest, pleasure or motivation in doing things*
Not at all
Several days
More than half the days
Nearly every day
2) Feeling down, depressed or hopeless*
Not at all
Several days
More than half the days
Nearly every day
3) Having trouble falling or staying asleep, or sleeping too much*
Not at all
Several days
More than half the days
Nearly every day
4) Feeling tired or having little energy*
Not at all
Several days
More than half the days
Nearly every day
5) Poor appetite or overeating*
Not at all
Several days
More than half the days
Nearly every day
6) Feeling bad about yourself or that you are a failure or have let yourself or your family down in some way*
Not at all
Several days
More than half the days
Nearly every day
7) Having trouble concentrating on things such as reading or watching television*
Not at all
Several days
More than half the days
Nearly every day
8) Moving or speaking so slowly that other people could notice, or the opposite, being so restless and moving much more than usual*
Not at all
Several days
More than half the days
Nearly every day
9) Having thoughts that you would be better off dead or of hurting yourself in some way*
Not at all
Several days
More than half the days
Nearly every day
GAD-7
Over the last 2 weeks, have you been bothered by any of the following problems?
1) Feeling nervous, anxious or on edge*
Not at all
Several days
More than half the days
Nearly every day
2) Not being able to stop or control worrying*
Not at all
Several days
More than half the days
Nearly every day
3) Worrying too much about different things*
Not at all
Several days
More than half the days
Nearly every day
4) Having trouble relaxing*
Not at all
Several days
More than half the days
Nearly every day
5) Being so restless that it is hard to sit still*
Not at all
Several days
More than half the days
Nearly every day
6) Becoming easily annoyed or irritable*
Not at all
Several days
More than half the days
Nearly every day
7) Feeling afraid as if something awful might happen*
Not at all
Several days
More than half the days
Nearly every day
Work & Social Adjustment
People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems look at each section and determine on the scale provided how much your problem impairs your ability to carry out the activity.
1) WORK - if you are retired or choose not to have a job for reasons unrelated to your problem, please select N/A (not applicable)*
0 - Not At All
1
2 - Slightly
3
4 - Definitely
5
6 - Markedly
7
8 - Very severely
N/A
2) HOME MANAGEMENT - Cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc*
0 - Not At All
1
2 - Slightly
3
4 - Definitely
5
6 - Markedly
7
8 - Very severely
3) SOCIAL LEISURE ACTIVITIES - With other people, e.g. parties, pubs, outings, entertaining etc*
0 - Not At All
1
2 - Slightly
3
4 - Definitely
5
6 - Markedly
7
8 - Very severely
4) PRIVATE LEISURE ACTIVITIES - Done alone, e.g. reading, gardening, sewing, hobbies, walking etc*
0 - Not At All
1
2 - Slightly
3
4 - Definitely
5
6 - Markedly
7
8 - Very severely
5) FAMILY AND RELATIONSHIPS - Form and maintain close relationships with others including the people that I live with*
0 - Not At All
1
2 - Slightly
3
4 - Definitely
5
6 - Markedly
7
8 - Very severely
Phobia Scales
Choose a number from the scale below to show how much you would avoid each of the situations or objects.
1) Social situations due to a fear of being embarrassed or making a fool of myself*
0 - Would not avoid it
1
2 - Slightly avoid it
3
4 - Definitely avoid it
5
6 - Markedly avoid it
7
8 - Always avoid it
2) Certain situations because of a fear of having a panic attack or other distressing symptoms (such as loss of bladder control, vomiting or dizziness)*
0 - Would not avoid it
1
2 - Slightly avoid it
3
4 - Definitely avoid it
5
6 - Markedly avoid it
7
8 - Always avoid it
3) Certain situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in confined spaces, driving or flying)*
0 - Would not avoid it
1
2 - Slightly avoid it
3
4 - Definitely avoid it
5
6 - Markedly avoid it
7
8 - Always avoid it
BACKGROUND INFORMATION
First language:*
Please Select A Value...
Akan (Ashanti)
Albanian
Amharic
Arabic
Bengali & Sylheti
Brawa & Somali
British Signing Language
Cantonese
Cantonese and Vietnamese
Creole
Dutch
English
Ethiopian
Farsi (Persian)
Finnish
Flemish
French
French creole
Gaelic
German
Greek
Gujarati
Hakka
Hausa
Hebrew
Hindi
Igbo (Ibo)
Italian
Japanese
Korean
Kurdish
Lingala
Luganda
Makaton (sign language)
Malayalam
Mandarin
Norwegian
Pashto (Pushtoo)
Patois
Polish
Portuguese
Punjabi
Russian
Serbian/Croatian
Sinhala
Somali
Spanish
Swahili
Swedish
Sylheti
Tagalog (Filipino)
Tamil
Thai
Tigrinya
Turkish
Urdu
Vietnamese
Welsh
Yoruba
Other
Religion/Faith:*
Please Select A Value...
No religious group or secular
Atheist / Agnostic
Church of England
Other protestant
Orthodox Christian
Roman Catholic
Other Christian
Muslim
Shi'ite Muslim
Sunni Muslim
Sikh
Jewish
Orthodox Jewish
Buddhist
Hindu
Jain
Parsi / Zoroastrian
Rastafarian
Any other religion
Not stated
Interpreter Required?:*
Yes
No
If yes, what language?:
Next of kin name:*
Next of kin relationship to you:*
Next of kin phone number:*
Special needs or adjustments: (for example, you are a wheelchair user)
What is your ethnicity?:*
Please Select A Value...
Asian or Asian British - Any other Asian background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Black or Black British - African
Black or Black British - Any other Black background
Black or Black British - Caribbean
White - British
White - Irish
White - Any other White background
Mixed - White and Asian
Mixed - Any other mixed background
Mixed - White and Black African
Mixed - White and Black Caribbean
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
HEALTH RELATED INFORMATION
Do you have a registered disability?:*
Yes
No
If Yes, please specify:
Behaviour and Emotional
Hearing
Manual Dexterity
Memory or ability to concentrate, learn or understand (Learning Disability)
Mobility and Gross Motor
Other
Perception of Physical Danger
Personal, Self Care and Continence
Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits etc)
Sight
Speech
If Other, please specify:
Any other health details which are important for us to know?:
EMPLOYMENT INFORMATION
What is your employment status?:*
Please Select A Value...
Employed full-time
Employed part-time
Unemployed
Full-time student
Retired
Full-time homemaker or carer
Voluntary work
Long-term sick or disabled
Not receiving benefits and not working or actively seeking work
Unpaid voluntary work, not working or actively seeking work
Not stated
What is your current employment attendance status?:*
Please Select A Value...
Employed and in work
Employed and off work through sickness leave
Not stated
N/A
How many hours do you work in a typical week?:*
Please Select A Value...
1-4 hours
5-15 hours
16-29 hours
30+ hours
N/A
Not known
I do not wish to disclose
Are you receiving statutory sick pay?:*
Yes
No
Not stated
Not known
Are you receiving benefits?:*
Yes
No
Not stated
Not known
If Yes, please tick all that apply:
Jobseeker's Allowance (JSA)
Employment and Support Allowance (ESA)
Universal Credit (UC)
Personal Independence Payment
Other Benefits
Would you like support from an Employment Advisor?:*
Yes
No
If Yes, what would you like help with?:
Do you work for the NHS? For example, an NHS Trust, Primary Care or a charity funded by Primary Care, CCG etc:*
Yes
No
Do you work in Social Care? For example, Local Authority, Care Home or providing care for residents in their home:*
Yes
No
SERVICE INFORMATION
We use your phone number to call and text you about appointment information. We use your email address to contact you about your referral and also to seek feedback while you are engaging with our service or shortly afterwards. Therapists may also use your email address to contact you about appointments and send you resources. Please make sure you have written it accurately on the first page of this form.
People have told us that emails from us sometimes go into their spam folders. Please check these folders in your email account to ensure that you haven’t missed correspondence from us.
Please select to confirm that we are able to contact you by:*
Phone
Text
Email
Letter
None of the above
If we are unable to reach you, can we leave a message?:*
Yes
No
Information you share with us is confidential between you, our service and your GP. The only time we will break this confidentiality is if we are concerned that there is a serious risk of harm to you or someone else. We store information on our IT system. This is confidential, and cannot be accessed by anyone outside of our service. We do share anonymous information with NHS England and other statutory bodies that monitor our performance. This information may include details on the number of people we see, what type of treatment they receive, or if they recovered. This does not include your name, address, contact details etc.
Please confirm you understand and agree to the above:*
Yes
If we think your needs are better met by another service, we would normally share your information in order to make a referral. Are you happy with this?:*
Yes
No
FURTHER INFORMATION
Have you ever received treatment (CBT/Counselling/other) for your mental health?:*
Yes
No
If yes, please provide details to include when, where and whether this was helpful:
Have you ever received a mental health diagnosis?:*
Yes
No
If yes, please provide details to include where and when you were diagnosed and what the diagnosis is:
Are you currently on a waiting list or receiving therapy from another mental health provider such as Oxleas?:*
Yes
No
If yes, please provide details:
People usually come to our service to be helped with depression/ low mood or different types of anxiety. If you feel that your main problem is depression, please continue with question 1. If you feel that the main problem is a type of anxiety, please continue with question 2.
If you are unsure, please choose the emotion that upsets you the most.
1. Sometimes, people are aware of what causes their depression. Please look at the options below and mark the one/s that best describe/s your experience:
Low mood linked to loss of a loved one.
Low mood linked to past or recent difficult life events (e.g. difficulties in the family or relationships, loss of a job, etc.)
Low mood linked to health problems and long term health conditions.
Other
If Other, please specify:
Please choose the option that is most relevant to you and has the strongest impact on your day to day mood and behaviour.
2. Please look at the types of anxiety people often experience below and mark the option/s that most closely describe/s your experience:
I am anxious about my health (e.g. I fear that I have or will develop a serious illness such as cancer, brain disease or other).
I am anxious about social situations and doing or saying something to embarrass myself.
I am anxious about the way I look like (e.g. my body, face or a body part).
I have always been a worrier and my worries escalate from small things to catastrophic scenarios and this is making me anxious. I seem to be anxious about many different things.
I experience a sudden rush of fear along with physical symptoms such as sweating, shaking, breathlessness, pounding heartbeat and nausea. I believe that this means I am going crazy, losing control or that something terrible will happen to me. These attacks also happen without warning, almost ”out of the blue”
My anxiety is linked to past traumatic event. Since the event, I have been feeling anxious / scared / emotional / angry / different. I have been experiencing flashbacks, nightmares or strong waves of emotions linked to the event.
My anxiety is linked to fear of harm coming to me or others due to possibility of contamination / making a mistake such as not checking the locks on doors/windows, appliances and items that can catch fire / acting carelessly or doing something that can bring bad luck to me or people I care about
I am anxious about specific objects, animals or activities (e.g. needles, blood, snakes, mice, being in confined spaces, being in crowded places, being in open spaces, etc…)
Other
If Other, please specify:
HOW ARE YOU CURRENTLY COPING WITH YOUR DEPRESSION/ANXIETY?
Are you currently prescribed medication?:*
Yes
No
If yes, please give details:
How do you think that therapy can help with your anxiety or depression at this time?:*
If you could focus on one problem in therapy, what problem would that be?:*
QUESTIONS
This section will ask a series of questions that you might find difficult to answer, or you may feel are not applicable. Please could you answer as honestly as possible, to help us ensure that you receive the correct level of support.
HAVE YOU THOUGHT ABOUT OR ACTUALLY TRIED TO END YOUR OWN LIFE IN THE PAST YEAR?*
YES
NO
IF YES DID YOU RECEIVE SUPPORT?
HAVE YOU EXPERIENCED ANY THOUGHTS OF OR HAVE YOU ACTUALLY SELF HARMED IN THE LAST MONTH?*
YES
NO
IF YES, PLEASE STATE IF THEY ARE JUST THOUGHTS OR DO YOU HAVE A PLAN?
HOW SERIOUS ARE YOU IN CARRYING OUT THIS PLAN?
Please Select A Value...
0 - NOT AT ALL
1
2
3
4
5
6
7
8
9
10 - DEFINITELY WOULD
WHAT WOULD STOP YOU?
HAVE YOU EVER THOUGHT ABOUT OR ACTUALLY HARMED ANYONE ELSE?*
YES
NO
IF YES, PLEASE PROVIDE DETAILS
DO YOU FIND THAT YOU ARE USING SUBSTANCES SUCH AS ALCOHOL OR ILLEGAL SUBSTANCES TO TRY AND COPE BETTER?*
YES
NO
IF SO WHICH SUBSTANCES ARE YOU USING? AND HOW MUCH DO YOU USE IN AN AVERAGE WEEK?
If you need urgent help, please refer to the contact details at the top of the form.
Do you see any reason why you would not be able to attend therapy at this current time?
If you cannot attend, would computerised Cognitive Behaviour Therapy interest you?
Yes
No
CCBT is made up of a package of online mental health treatment programmes, mostly based on CBT, which help people to overcome common mental health problems
Usage is overseen by a supporter who;
- Monitor and review client progress.
- Provides feedback, guidance and encouragement, via regular written/phone reviews.
Thank you for completing the above information. This information will be uploaded onto our system and your assessment will be discussed in the next case management meeting where the most suitable treatment will be decided in line with recommended NICE guidance. If you are unsuitable for the service, we will contact you and inform you of this decision.
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