Referral Form

Welcome to Talking Therapies online support delivered on SilverCloud.

To refer yourself please complete form below. Once the form has been completed you will receive an email from SilverCloud within approx. 15 minutes, with a link to get you started with the programme (appearing from do-not-reply@silvercloudhealth.com).

When you have received this email please click “accept invite” and create your account – this takes around 10-15 minutes. We aim to review your referral within 3 working days.

If you require urgent support, please contact:

• Your GP practice or NHS 111

• The Samaritans on 116 123

• In an emergency dial 999

If you would prefer to talk to someone rather than using SilverCloud online, please call our admin team on 0300 365 2000 (option 2).

Title:*

First Name:*

Last Name:*

Date of birth (17+ only):*

Gender:*

Ethnicity*

Address Line 1:*

Postcode:*

Mobile Number:

May we leave a message on this number?

Yes

No

Would you like text reminders of appointments?

Yes

No

Landline Number:

Email Address:*

GP Practice Name (Berkshire only):*

Name of your next of kin:

Phone number of your next of kin:

Relationship to you of next of kin:

Are you, or is your partner, pregnant?:*

Do you have a child under the age of 2?:*

Are you currently working with any other mental health services?:*

Yes

No

Do you have a long term condition that we need to be made aware of?:*

Yes

No

Not sure

If yes, please specify:

LTC Other, please specify

Please tell us more about your long term health condition if you believe this is relevant to your mood and emotional wellbeing:

Do you have a probation officer allocated to you? *

Yes

No

If yes, please provide the following details of your probation officer so that we can obtain a risk assessment;

Probation Officer Name

Probation Officer Telephone Number

Probation Officer Location

How did you hear about the service?*

If other, please specify

Please complete the captcha

Self Referral Form