Referral Form

Plymouth Options offer treatment for people experiencing common mental health difficulties.

Please complete the referral form in as much detail as possible. The form can take up to 20 minutes to complete.

Your referral will be processed and we will contact you in due course on the treatment most suited to your difficulties. Please note that the initial treatment option can often be a course or online-therapy, particularly for people using our service for the first time.

Plymouth Options is not an acute service so is not suitable for people;

- Who are a high risk to themselves or others, such as current risk of suicide or serious self-harm

- Already undertaking another form of psychological therapy

- Who are using substances such as alcohol or recreational drugs to self-medicate

- Who have current severe or enduring mental health needs and as such require specialist services

- Plymouth Options is not an emergency service. If there is a life-threatening situation you need to contact emergency services on 999 or present at the nearest A&E department. For all non-emergency medical/mental health interventions please contact your GP during normal working hours. You can also phone NHS 111 for urgent medical problems who are open 24 hours, 7 days per week. Additionally you can contact the Samaritans to talk about mental health issues on: 116123

Title*

First Name*

Last Name*

Date of Birth*

Gender*

Male

Female

Not specified

I prefer not to say

Address Line 1*

Address Line 2

Town/City

County

Postcode*

Telephone Number:*

Email Address*

Preferred method of contact, click all that apply*

Telephone

Email

Post

If you selected telephone, are we able to leave a voicemail?

Yes

No

If you selected telephone, are we able to send text message reminders?

Yes

No

Would you like to provide Next of Kin contact details?

Yes

No

Next of Kin Name

Next of Kin Contact Number

We may share appropriate clinical information with your GP

GP Name (if known)

GP Surgery Name*

Please give as much detail as possible

What are the current difficulties you are seeking help with?*

What is the main impact these difficulties are having on your day-to-day life? (e.g. work, relationships, social activities etc.)*

How long have you been experiencing these difficulties (weeks/months/years)? And what has motivated you to seek help now?*

What are your goals and expectations for treatment?*

Have you ever had a mental health diagnosis, for example Bi-Polar, Personality disorder, Psychosis? (If so, please provide details)*

Do you have any current / previous involvement with any other mental health service, drug & alcohol service, probation service or other support service? (If so, please provide details)*

Please complete each question in the questionnaires below to help us identify symptoms of low mood and/or anxiety:

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

If you answered 'several days', ‘more than half the days’ or ‘nearly every day’ to Question 9 above, please complete the following questions:

Do you have any current plans to end your life?

Yes

No

How likely is it that you will act on these thoughts or plans to end your life?

What is stopping you from acting on these thoughts?

Do you feel you pose a risk to others, or are at risk from anyone else at this time? (If so please provide details)

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

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)*

2) HOME MANAGEMENT - Cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc*

3) SOCIAL LEISURE ACTIVITIES - With other people, e.g. parties, pubs, outings, entertaining etc*

4) PRIVATE LEISURE ACTIVITIES - Done alone, e.g. reading, gardening, sewing, hobbies, walking etc*

5) FAMILY AND RELATIONSHIPS - Form and maintain close relationships with others including the people that I live with*

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*

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)*

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)*

Nationality

Ethnicity

Disability

Religion

Sexuality

Language

Do you require an interpreter?

Yes

No

Are you currently pregnant or had a baby in the last 12 months?

Yes

No

Do you have any long-term medical conditions?

If yes, please select

Please indicate your current employment status

Are you currently receiving Statutory Sick Pay or in work but on sick leave?

Yes

No

Don't know

Prefer not to say

Are you currently receiving Job Seekers Allowance, Income Support or Employment Support Allowance?

Yes

No

Don't know

Prefer not to say

Are you taking any current medication? (If so please provide details)

Are you currently, or have you previously served as, a member of the Armed Forces?

Please use this box to let us know of any restrictions on when or how we can contact you, your availability for appointments or any other information you wish us to consider regarding your referral*

Click one or all that apply*

If Other, please specify

Thank you for completing this referral form.

One of our clinicians will review your information and contact you by your preferred method with the treatment options available. If we need any further details or clarity on the information you have provided then we may contact you to arrange a brief triage assessment call.

The initial treatment option offered may be either one of our psycho-educational Cognitive Behavioural Therapy (CBT) courses or our online CBT program, as detailed below:

Psycho-educational courses

- Psycho-educational courses provide a good introduction to CBT and are taught in a classroom environment. They are designed to help you understand your difficulties and equip you with tools to manage your symptoms. The full list of our courses can be viewed on our website.

Online CBT programs

- Online CBT programs are designed to help with problems of anxiety, stress or depression. We also offer specific online programs for patients suffering with long term physical health conditions (e.g. COPD, Chronic pain), as well as specifically designed programs for students. The full list of online programs can be viewed on our website.

Many people find the courses are enough to help them through their current difficulties and don't require any further support. If at the end of the course you do require further help then we can review this at that time.

Please indicate below if you have a particular preference:

Psycho-educational Course

Online CBT Program

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Plymouth Options Self-Referral Form

Please Note

Personal Details

GP Details

Reason for Referral

Questionnaires

PHQ-9

GAD-7

Work & Social Adjustment

Phobia Scales

Further Information

Where did you hear about us?

What Happens Next