Referral Form

If the person you are referring requires immediate support please call their GP, call the Camden and Islington crisis line on 0800 917 3333 or urge them to visit their local Accident & Emergency department.

Please provide as much information as possible so we can process your referral efficiently. We offer a range of mainly short-term, goal-focused psychological interventions to people who are looking to make changes in their lives. If you are unsure if our service is the right service for your patient or if you have any problems completing this online form, you can call us to discuss this.

Referrer name:*

Job Title of Referrer:*

Referrer organisation:*

Contact e-mail address:*

Contact phone number:*

Title:*

First Name:*

Last Name:*

NHS Number:

Date of Birth:*

Gender:*

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Mobile Phone Number:

Permission to Leave Voicemail on mobile?:

Yes

No

Permission to send SMS Text reminders?:

Yes

No

Home Phone Number:

Permission to leave voicemail on landline?:

Yes

No

Email Address:

Please note, we can only accept referrals for patients registered with a GP in Camden and Islington, or who live in Camden and Islington.

Does the patient have a GP in Camden or Islington?:*

Yes, they have a GP in Camden or live in Camden

Yes, they have a GP in Islington or live in Islington

GP Surgery:*

GP Name:

Nationality:*

Ethnicity:*

Do they need an interpreter?:*

Yes

No

Preferred Language:

Sexuality:*

Does the patient have any disabilities or special access requirements? e.g. visual impairment, hearing difficulties, mobility issues:

Yes

No

Unknown

If yes, please specify:

Any long term medical conditions?:*

If Other, please specify:

Is the patient pregnant or do they have any children under 1 or under 2?:*

Are they an NHS or social care member of staff working in North Central London?:*

Yes

No

Don't know

Are they ex-British Armed Forces?:*

Reason for referral (please give a full and complete reason for referral, including existing and historic mental health diagnoses, interventions already tried and response to these):* (Please use the continuation box below if required)

Continuation:

Please indicate if you have a view about what intervention might be helpful:

Is the person receiving any help from other services?:*

Yes

No

If yes, please give details:

Are they prescribed any medication for their mood?:*

Yes

No

Unknown

If yes, please give details:

Please give full details of any Current RISK to self or others, Current RISK from others, safeguarding issues, substance misuse: (Please use the continuation box below if required)

Continuation:

Relevant previous history including treatment, self harm, or previous suicide attempts, forensic history or safeguarding issues: (Please use the continuation box below if required)

Continuation:

Please complete the captcha

Health Professional Referral Form

Referrer Details

Patient Details

GP Details

Further Details

Referral Reason