Referral Form

* indicates a required field

Title*

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

How did you hear about us?*

If other please specify

Gender*

Male

Female

Other

Is this your birth gender?*

Yes

No

If NO how do you identify?

What is your preferred pro-noun?

Sexuality*

Ethnicity*

Do you speak English?

Yes

No

Do you require an interpreter?*

Yes

No

If yes, please specify your language

Does the patient have someone that they consent us speaking with who could help book the 1st appointment?

Name

Contact Number

Religion

Are you pregnant/have or have you given birth in the last 12 months?*

Yes

No

Have you ever served in the armed Forces?*

Yes

No

If yes for the above is this

Ex Military

Current Military

Are you a NHS worker, Care home Worker?

Yes

No

GP Surgery*

GP Name*

GP Address*

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)

Do you have any diagnosed mental health conditions?*

In relation to your mental health, are you currently being seen by any other service?*

Yes

No

If yes please give details

To help us to support you to access the service, can you let us know if any of the following apply to you:

If other, please state

Do you have a Long-Term Physical health condition?*

Yes

No

If answered yes to the above please choose:

If other, please state

We can support you with difficulties in coming to terms with a long-term physical health condition and in any learning to follow health advice. Are you referring to Talk Wandsworth for this type of support?

Yes

No

Which of the services do you feel you need? (you can select both)

Wellbeing

Psychological

Not sure

Can you give brief details on the main reason you are referring yourself to the service?*

Would you feel confident enough with computers/technology to access online support or programmes if offered?*

Yes

No

Please use this space for specific requests, or additional information you think important for us to know

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.

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

Are you referring on behalf of someone else?*

Yes (please complete the details below)

No

Referrer Name

Referrer Organisation

Referrer Email

Referrer Contact Number

Please complete the captcha

Talk Wandsworth Self Referral Form

Personal Details

About You

GP Details

Additional Information