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/
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
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Title
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First Name
Last Name
Date of Birth
Gender
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Home Number
Can we leave a voicemail?
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Mobile Number
Can we send you text message reminders?
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Can we leave a voicemail?
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E-mail
GP Name
GP Practice
Nationality
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Sexuality
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Do you have a long term medical condition? (e.g. cancer, diabetes, heart disease, stroke)
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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?
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Ethnicity
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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?
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Grenfell Outreach
BMER Outreach
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Older Adults Outreach
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Word of Mouth
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