Talk Wandsworth Self Referral Form
NB: This is a self-referral form. If you are a professional, please use eRS or alternatively the professional referral form (if you do not have access to eRS) on our website.
* indicates a required field
Personal Details
Title*
Please Select A Value...
Mr
Mrs
Miss
Ms
Mx
Dr
Rev
Prof
First Name*
Last Name*
Date of Birth*
Address Line 1*
Address Line 2
Town/City*
County*
Postcode*
Email*
Home Number
Mobile Number*
Please tick any communication methods you are happy for us to use:
Letters to your home address
Text message appointment reminders and service information to mobile number
Voicemails on home number provided
Voicemails on mobile number provided
Email correspondence
Gender*
Male
Female
Non-binary
Others
Is this your birth gender?*
Yes
No
What is your preferred pro-noun?
Sexuality*
Please Select A Value...
Heterosexual
Lesbian or gay
Bi-sexual
Person asked and does not know or is not sure
Not stated (Person asked but declined to provide a response)
Ethnicity*
Please Select A Value...
White - British
White - Irish
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Any other Asian background
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Any other Black backgrond
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
GP Details
GP Surgery*
GP Address*
GP Name (if known)
Your NHS Number (if known)
Can we contact your GP?*
Yes
No
(please note in certain circumstances (such as where significant risk is identified) we will be obliged to share information with your GP)
About You
How did you hear about us?*
Please Select A Value...
Community event or promotion
EMHIP project
Faith organisation
Future first’
GP recommendation
Internet search engine, e.g. Google
Job Centre Plus
Local Charity
Other Health Services
Social media
Text link sent to phone from GP
Word of mouth
Website search
Other
Can you give brief details on the main reason you are referring yourself to the service?*
Do you have a diagnosed mental health condition?*
Yes
No
If yes, please give details.
In relation to your mental health, are you currently being seen by any other service?*
Yes
No
If yes please give details
Do you have a Long-Term Physical health condition?*
Yes
No
If answered yes to the above please choose:
Please Select A Value...
Diabetes
Heart disease
Chronic Obstructive Pulmonary Disease (COPD)
Long COVID
Other
If other, please state
We offer support for people who are having difficulties in coming to terms with a long-term physical health condition. Are you referring yourself for this type of support?
Yes
No
Are you pregnant/have or have you given birth in the last 12 months?*
Yes
No
Have you ever served in the armed Forces?*
Please Select A Value...
Yes - ex services
Dependant of a ex-serving member
No
Not stated (Person asked but declined to provide a response)
Unknown (Person asked and does not know or isn't sure)
If yes for the above is this Ex Military or Current Military?
Ex Military
Current Military
Do you require an interpreter?*
Yes
No
If yes, please specify your language
Please Select A Value...
Akan Ashanti
Albanian
Amharic
Arabic
Bengali and Sylheti
Brawa and Somali
British Signing Language
Cantonese
Cantonese and Vietnamese
Creole
Dutch
English
Ethiopian
Farsi Persian
Finnish
Flemish
French
French Creole
Gaelic
German
Greek
Gurjarati
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 Croation
Sinhala
Somali
Spanish
Swahili
Sweedish
Sylheti
Tagalog Filipino
Tamil
Thai
Tigrinya
Turkish
Urdu
Vietnamese
Welsh
Yoruba
Other
Your Support Needs
To help us to support you to access the service, can you let us know if any of the following apply to you:
Learning Disability
Hearing Impairment
Visual Impairment
Mobility Issues
Difficulties with reading and/or writing
Other (please state below)
If other, please state
Are you being supported by the Community Learning Disability Team?
Yes
No
If answered yes to the above, can we contact them to discuss your referral to us?
Yes
No
Additional Information
Are you confident with computers/technology to access online support or programmes if offered?*
Yes
No
Please use this space for any requests, or additional information that you think is important for us to know, e.g., contact details for a Next of Kin, a nominated person to help facilitate booking your appointment, mobility requirements etc.
If we feel that another Trust service is better placed to help you at this time, we would like to refer you directly to them. Please select this option if you DO NOT want us to share your information in such circumstances.
Consent to onward referral:
I do not wish to share my information
In order to reduce waiting times and ensure timely assessment and treatment, we work closely in partnership with digital providers. These providers are currently Xyla digital therapies, IESO and Silver Cloud.
Do you consent to sharing your information and being contacted by these services if appropriate?*
Yes
No
Please complete the captcha
Submit
Cancel