Self Referral Form
You will be eligible for this service if you are registered with a GP in Kensington and Chelsea, or in the Queens Park and Paddington area of Westminster - if you do not fit this criteria find your local service at https://www.nhs.uk/service-search/mental-health/find-a-psychological-therapies-service. You can also access this service if you work for the NHS and would like support from the service, if you are an NHS staff member you do not need to be registered with a GP in the area. Please indicate clearly on the referral form if you are an NHS staff member.
This self-referral form is a way for you to access psychological support and advice from your local talking therapies service. This service is for people who are experiencing stress, worry or low mood or struggling to cope with everyday life due to emotional difficulties. If you have a history of serious mental health issues or drug and alcohol problems it is possible we are not the best service to help you and we suggest you go to your GP for advice.
We are not able to provide immediate support in an emergency. If you require immediate help please contact your GP, your local Accident & Emergency Department, or call the Urgent Advice Line on 0800 0234 650 open 24 hours.
Through completing this form you are consenting to have this information stored confidentially on a secure electronic system separate from your GP's system and for your GP to be informed of your contact with us.
If you are unable to complete this form for any reason or if you would prefer to complete this form on paper, or give your details over the phone, please call 0203 317 4200, or email cnw-tr.clw@nhs.net
By providing these details you are giving consent for us to contact you regarding confidential information.
Personal Details
Are you filling in this form for yourself?
Yes
No
Title
Please Select a Value...
Mr
Mrs
Miss
Ms
Mx
Dr
Rev
Prof
First Name
Last Name
Date of Birth
Gender
Male
Female
Transgender Male
Transgender Female
Gender Non-Binary
Gender Fluid / Gender Queer
Intersex
Not known
Not specified
Unwilling to divulge
Are you able to have your appointments in English?
Yes
No
If you have selected No, please specify the language (including BSL), and we will organise an assessment with an interpreter (please note that we use professional interpreters and will not use family members/friends to interpret for you).
Please state language:
Address Line 1
Address Line 2
Town/City
County
Postcode
Home Number
Can we leave a voicemail?
Yes
No
Mobile Number
Can we send you text message reminders?
Yes
No
Can we leave a voicemail?
Yes
No
Please note that, whilst NHS email is secure, we cannot guarantee that your own email server will be so. Please only give us your email if you are happy for confidential information to be sent to your email address.
Email
Can we correspond with you via email?
Yes
No
GP Details
GP Name
GP Surgery
GP Surgery Address
Further Information
We ask these questions to ensure that our service is being accessed by everyone and to ensure any specific requirements are met.
Nationality
Please Select A Value...
British
English
Irish
Scottish
Welsh
Other
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
Sexuality
Please Select A Value...
Heterosexual
Gay (male)
Lesbian / Gay (female)
Bi-sexual
Asexual
Questioning
Other
Not known
Unwilling to divulge
Disability
Please Select A Value...
No Disability
Behaviour and Emotional
Hearing
Manual Dexterity
Memory or ability to concentrate, learn or understand (Learning Disability)
Mobility and Gross Motor
Perception of Physical Danger
Personal, Self Care and Continence
Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits, etc)
Sight
Speech
Other
Do not wish to say
If Other, please specify:
Are you an NHS or social care front line worker?
Yes
No
Are you, or your partner, pregnant or do you have any children under 1 or under 5?
Please Select A Value...
I am pregnant
My partner is pregnant
Children under 1
Children aged 1-5
No
N/A
Referral Information
Please describe the problem you need help with
Have you ever received treatment for these difficulties?
Yes
No
Please describe any treatment or support you’ve had for these difficulties
What type of help are you looking for?
Do you have any long-term medical conditions?
Please Select A Value...
None
Asthma
Cancer
Chronic Fatigue Syndrome (CFS)
Dementia
Epilepsy
Heart failure
High blood pressure / hypertension
Musculoskeletal Disorder (MSK)
Chronic Obstructive Pulmonary Disease (COPD)
Coronary Heart Disease
Diabetes
Chronic pain or fibromyalgia
Irritable Bowel Syndrome (IBS) or digestive tract condition
Medically unexplained symptoms (MUS)
Parkinson's
Other cardiovascular conditions
Other
If Other, please specify
Is there anything you would like us to know?
Where did you hear about us?
Please Select A Value...
Word of Mouth
GP recommended referral
Another health professional
Friend and Family
nhstalk2us
Social Media (e.g. Twitter, Facebook, Instagram)
Internet Search Engine
Community Outreach Event
Poster and Leaflet
Radio/TV
Other
If other, please specify
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