Referral Form

TALKWORKS, Devon’s NHS Talking Therapies Service, offers free and confidential psychological therapy. We are here to help adults, age 18+, living in Devon (outside Plymouth), who may be experiencing a common mental health problem such as stress, anxiety, depression or insomnia. We offer a range of talking therapies and treatment options to help get you back on track and feel more like yourself again.

You can self-refer to our service by filling out the form below. We will then contact you to arrange an initial appointment with one of our NHS clinicians, who will talk to you about the difficulties you would like help with and the treatment that TALKWORKS offers.

Are you in need of urgent mental health support or are you in crisis? TALKWORKS is not a crisis response service, and if you need help urgently please visit the Devon Partnership NHS Trust website and click the “I need help now” button.

Your Title:*

Your first name:*

Your last name:*

Your date of birth:* (TALKWORKS is a service for people aged 18 and over)

Your gender:*

Address Line 1:*

Address Line 2:

City/Town:*

Postcode:*

Email address:*

Mobile phone number:

Can we leave a voicemail on this number?

Yes

No

Landline number:

Can we leave a voicemail on this number?

Yes

No

If you do not want us to leave a voicemail and we are unable to speak to you, we will contact you via email instead.

Please tick here to confirm you are happy to receive appointment information and reminders from us by text message:

Yes

Your GP’s name:

Your GP’s surgery:*

We are required to let your GP (doctor) know that you are coming along to see us. If you do not know the name of your GP, you can leave this blank and just include the surgery name.

For your initial appointment would you prefer (please tick any that apply):

A face-to-face appointment

A telephone appointment

A video call appointment

No preference

Do you have any additional needs that we need to be aware of? (e.g. mobility needs, sight or hearing difficulties, an interpreter if English is not your first language):

Yes

No

If 'Yes', what help do you need?

TALKWORKS often employ clinicians who are undertaking clinical training. All our trainee practitioners have passed robust competency assessments at Exeter University, and are closely supervised by qualified and experienced members of our team. Your confirmation letter will let you know if your initial appointment is booked with a trainee. If you have any concerns about this, please call us on 0300 555 3344.

Please could you share the following information about yourself?

Your ethnicity:*

Your sexuality:*

Do you have a disability?

Are you a carer? (for someone other than a child):

Yes

No

Do you currently experience any difficulties with reading or writing?

Yes

No

If 'Yes', please tell us more about this if you are able to:

Do you have a long-term physical health condition that impacts on your mental health?

If 'Yes', please tell us a bit more about your long term physical health condition:

Did a healthcare professional suggest you make a self-referral to access our specialist 'Talking Health' team due your physical health condition?

Yes

No

Are you currently pregnant or do you have a child under the age of two years old?

Yes

No

Do you have any current involvement with the Probation Service?

Yes

No

If you have answered YES, we will need to contact the Probation Service before we can proceed with booking an appointment for you.

Please tick here to confirm you consent to us doing so:

Yes

Have you recently seen, are you currently seeing, or are you waiting to see anyone from any other mental health or drug and alcohol service?

Yes

No

If 'Yes', please provide any details you can about the people or services you have recently seen, any treatment you have recently had, or any service you are currently waiting to see:

In the event of an emergency, please provide the details of someone who we can contact:

First name:

Last name:

Phone number:

Relationship to you:

One final question, how did you hear about TALKWORKS?

I agree to be contacted by TALKWORKS to progress my referral to the service:*

Yes

We share information with the Department of Health to ensure that our service is accessible to all and meets national quality standards. This data is transferred and used securely and it is impossible to identify any individual person in the national statistics. If you have concerns about this, or would like to be excluded from this data, please let the clinician know when you meet with them. Your details will be retained on our secure electronic system. If you have any concerns about this please let us know when we contact you.

Please complete the captcha

SELF REFERRAL FORM

Step 1: About You

Step 2: Contact Details

Step 3: Your appointment

Step 4: Please tell us a bit more about yourself…

Step 5: