Professional Referral Form
Please note that unless you are NHS or social care staff, we can only accept referrals from people aged 16 or over who are registered with a Barnet or Enfield GP surgery.
We are unable to accept referrals if you have a primary alcohol or drug misuse problem, or if you are already being seen by other secondary care or specialist mental health services.
We are also unable to offer immediate crisis support.
Referrer Information
Name:*
Address:*
Role:*
Tel:*
Email:*
Client Information
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Mx
Dr
Rev
Prof
Lord
First Name:*
Surname:*
NHS No:*
Date of Birth:*
Address Line 1:*
Address Line 2:
Town/City:*
County:
Postcode:*
Email:*
If you do not have client's email id please write 'not available'.
Mobile Tel:*
Permission to contact by SMS:*
Yes
No
Permission to contact by email:*
Yes
No
Where is the GP practice?:*
Barnet
Enfield
Other (only if the referral is for NHS or Social care staff)
GP Practice:*
GP Name:
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 background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Turkish
Other Ethnic Groups - Syrian
Other Ethnic Groups - Iranian
Other Ethnic Groups - Kurdish
Other Ethnic Groups - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
First language (if not English):
Needs interpreter?:*
Yes
No
Please state language:
Gender:*
Male
Female
Transgender Man
Transgender Woman
Intersex
Gender-fluid / Gender-queer
Gender non-binary
Other
Not disclosed
Does this client have special access requirements?:
Yes
No
If YES, please describe:
Is this person receiving help from other services:
Yes
No
If YES, please give details:
Client (or partner) pregnant or child under 2?:
Yes
No
Give details:
Does the individual have a long term condition:
Yes
No
If yes, please give details here:
Arthritis
Asthma
Cancer - in Treatment
Cancer in Remission
Chronic Fatigue Syndrome
Chronic Kidney Disease
Chronic Obstructive Pulmonary Disease (COPD)
Chronic Pain
Crohn's disease
Dementia
Diabetes Type 1 (Insulin Dependent)
Diabetes Type 2 (Non-Insulin Dependent)
Endometriosis
Epilepsy
Osteoarthritis
Fibromyalgia
Ischemic heart disease
Heart Condition (including Past Heart Attack)
Disorder of Liver
Coronary Heart Disease
Hepatitis
HIV
Hypertension
Chronic Heart disease
Irritable bowel syndrome
Lupus
Cardiac arrest
Medically unexplained symptoms
Breathlessness
Migraine
Multiple Sclerosis
Musculoskeletal Disorder (MSK)
Other digestive tract conditions
Parkinsons Disease
PCOS (Polycystic ovary syndrome)
Post Covid-19 Syndrome
Rheumatoid arthritis
Sickle Cell Disease
Skin condition including Eczema
Stroke and Transient Ischaemic Attack
Tinnitus
Woman's Health - Menopausal symptoms
Woman's Health - Pre-Menstrual Syndrome
Other
IF Other, please specify:
Is the main reason for this referral related to long-term health condition(s)?*
Please Select A Value...
Yes
No
Reason for Referral
Reason for referral (as detailed as possible) including diagnosis /presenting problems. In your opinion how would they benefit from psychological treatment:*
Have they received/are receiving treatment? Please describe. Have they engaged or are they currently engaging in psychological treatment?:*
Current Risks
Please note: We will not accept referrals of individuals who are at high risk and who require urgent help.
Current Risk:
To Self
To Others
From Others (please specify if experiencing ongoing domestic abuse)
To Children
If ticked, please describe the nature of the risk and what support is in place:
Any other information that may be relevant to the care and support of this patient?:
Please complete the captcha
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