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://beta.nhs.uk/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.
To meet the challenge of Covid-19 we have temporarily changed the way we work to provide support to people who are self isolating or anxious about the virus as well as continuing to provide support for people experiencing stress, worry or low mood. We are also offering support to NHS staff affected by Covid-19. We are offering brief focused support by telephone, video call or online treatments.
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
Dr
Rev
Prof
First Name
Last Name
Date of Birth
Gender
Male
Female
Not specified
Not known
Address Line 1
Address Line 2
Town/City
County
Postcode
Can we write to you at your address?
Yes
No
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
E-mail
GP Name
GP Practice
Nationality
Please Select a Value...
English
Scottish
Welsh
Irish
British
Other
Sexuality
Heterosexual
Gay/Lesbian
Bisexual
Other
Do not wish to say
Do you have a long term medical condition? (e.g. cancer, diabetes, heart disease, stroke)
Please Select a Value...
Yes
No
Don't Know/Not Sure
Do not wish to say
If yes, please describe the nature of your condition
Are you a carer for someone over 18 who lives in the borough of Kensington & Chelsea?
Yes
No
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
Any other mixed background
Asian or Asian British, Indian
Asian or Asian British, Pakistani
Asian or Asian British, Bangladeshi
Any other Asian background
Black or Black British, Caribbean
Black or Black British, African
Any other Black background
Other Ethnic Groups, Chinese
Any other ethnic group
Not Stated
Not Known
Do you have any specific needs or disabilities - e.g. Mobility problems, need for interpreter? If yes, please describe
Please describe the problem you need help with
Have you ever received, or are currently receiving, treatment or support for these difficulties? If yes, please describe
Where did you hear about us?
Please Select A Value...
Grenfell Outreach
BMER Outreach
LTC Outreach
Older Adults Outreach
Other Outreach
Service Promotion
Word of Mouth
Arts Therapies
Please complete the captcha
Submit
Cancel