Health Care Professional Referral
Please note that referrals can be made on behalf of someone else with their consent. Please ensure that the individual is fully aware that you are making the referral.
Fields marked with a * are required.
Referrer Details
Referrer Name:*
Job Title of Referrer:*
Referrer organisation/service:*
Contact e-mail address:*
Contact phone number:*
GP Details
We are only able to accept referrals for those registered with a GP Practice in Hounslow.
GP Name:*
GP Practice & Address:*
GP Email Address:*
Patient Details
NHS Number:*
Title:*
Please Select A Value...
Mr
Miss
Mrs
Ms
Mx
Dr
Prof
Rev
They
Patient First Name (In Full):*
Patient Preferred Name:
Patient Last Name:*
Gender:*
Female - Including Trans Woman
Gender-Fluid
Gender-Queer
Male - Including Trans Man
Non-Binary
Other
Prefer not to disclose
Not known
What are the patient’s preferred pronouns? (ie he/him, she/hers, they, etc):
Please Select A Value...
Ae/Aer/Aer
Ey/Em/Eir
Fae/Faer/Faer
He/Him/His
Per/Per/Pers
She/Her/Her
They/Them/Their
Ve/Ver/Vers
Xe/Xem/Xyr
Ze/Hir/Hir
Date of Birth:*
Address Line 1:*
Address Line 2:
Town:*
County:*
Postcode:*
Mobile Number:*
The patient consents to messages:*
No
Yes
The patient consents to SMS Messages:*
No
Yes
Home Number:
The patient consents to messages:
No
Yes
Email Address:* (If you do not have an email address, please input the following: noemail@nhs.net)
Please note, in an attempt to save the planet Hounslow IAPT are making every effort to go paperless. They will therefore receive correspondence via secure email. Should they have any difficulties with this, please indicate you prefer to receive letters by post.
Please specify:*
The patient consents to receiving correspondence via email
The patient prefers to receive correspondence via post
Patient Demographic Information
What is the patients nationality?:*
Please Select A Value...
British
English
Irish
Scottish
Welsh
Other
What is the patients ethnicity?:*
Please Select A Value...
White - English, Welsh, Scottish, Northern Irish or 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 or Multiple Ethnic 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/African/Caribbean background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
What is the patients religion?:*
Please Select A Value...
Agnostic
Any other religion
Baha'i
Buddhist
Christian
Hindu
Jain
Jewish
Muslim
Not religious/ no religion
Pagan
Patient does not wish to state
Patient Religion Unknown (Patient not asked)
Sikh
Zoroastrian
What is the patients sexual orientation?:*
Please Select A Value...
Heterosexual
Lesbian or gay
Bisexual
Other
Not known
Does not wish to state
Unknown
Is the patient Ex-British Armed Forces?:*
Please Select A Value...
Dependant of a ex-serving member
No
Not stated (Person asked but declined to provide a response)
Unknown (Person asked and does not know or isn't sure)
Yes - ex services
Disability Status:*
No Perceived Disability
Has Disability
If 'Has Disability' selected, please confirm nature of disability:
Behaviour and Emotional
Hearing Impairment
Manual Dexterity
Learning Disability
Mobility and Gross Motor
Other
Perception of Physical Danger
Personal, Self Care and Continence
Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits etc)
Visually Impaired
Speech Difficulties
Does the patient require a translator / interpreter?*
Yes
No
If yes, what language?
Accessibility Information Status:*
Has accessibility information requirements
No accessibility requirements
If 'Has Accessibility information requirements' please provide details
Next of Kin Details
Who is patients Next of Kin? Please provide their name:*
What is their relationship to the patient?:*
What telephone number can the Next of Kin be contacted on?:*
Is the patient happy for us to contact them / speak to them about their treatment?:*
Yes
No
Referral Information – Risk
Risk of Harm To Self
(e.g. suicidal ideation, suicide attempts; self-harm; self-neglect)
Current?*
Yes
No
If Yes please give details (date/nature)
Risk of Harm From Others
(e.g. domestic violence, bullying)
Current?*
Yes
No
If Yes please give details (date/nature)
History?*
Yes
No
If Yes please give details (date/nature)
Risk of Harm To Others
(e.g. violence, aggression, risk to children)
Current?*
Yes
No
If Yes please give details (date/nature)
History?*
Yes
No
If Yes please give details (date/nature)
HOUNSLOW IAPT IS NOT AN EMERGENCY SERVICE. If the patient is at active / current risk of harm to self, to others or from others, please refer the patient to West London Single Point of Access
If you have identified any risks above, what is the risk management plan?
Any current or previous use of mental health services/ counselling?*
Yes
No
If yes, please give details:
Any concerns about drug/alcohol use?*
Yes
No
If yes, please give details:
Referral Information – Mental Health
Has this referral been discussed with the patient?*
Yes
No
What would you like to refer this patient for?*
Please Select A Value...
Cognitive Behavioural Therapy
Counselling
LTC Support
Employment Support
What is the main problem you would like support with?:*
Please Select A Value...
Anxiety
Depression/Low Mood
Worry
Stress
Specific Fear (e.g Heights, Social Situations)
Low self-esteem
Anger
Traumatic/Distressing Experiences
Obsessive Compulsive Disorder
My Mind & Bump (Antenatal) Workshop ONLY
My Mind & Bump (Postnatal) Workshop ONLY
Other
If you have selected Traumatic/Distressing Experiences, please select one of the following:
Please Select A Value...
Not Applicable
Bereavement
Single Incident (i.e. car crash)
Historic Domestic Abuse
If other, please specify below:
Does the patient have a long-term condition?:*
Cardiac condition
COPD
Covid Syndrome / Long Covid
Diabetes
Other
None
If other, please specify?
Is the patient currently open to/ Have you or any other HCP referred this patient to any Secondary Care Mental Health Services (e.g. Single Point of Access, Crisis and Assessment Team (CATT), Liaison Psychiatry, MiNT Team)?:*
Yes
No
Don't Know
If Yes, please give details, including any current or previous diagnosis (if known):
Is the patient currently taking any antidepressants or anti-anxiety medication?:
Yes
No
If yes, please give the name of the medication and the dosage prescribed:
Perinatal
Is the patient currently pregnant or an expectant father?*
Yes
No
If yes, please provide the due date:
Is the patient a parent of a child under the age of 1 years old?*
Yes
No
If yes, please provide the child’s date of birth:
NHS Worker
Is the patient employed as an NHS Worker?:*
Yes
No
If yes, What is their job title and which NHS Trust are they employed by:
NB: In the interests of confidentiality, if they are employed by West London NHS Trust, we will forward the referral to Keeping Well to seek a service outside of this Trust to process your referral. For further information visit: http://www.keepingwellnwl.nhs.uk.
Carer / Support
Is the patient a Carer (Registered or Informal)?
Yes
No
Does the patient have a carer (Registered or Informal)?:*
Yes
No
If yes: Would they like their carer to be involved in their treatment?:
Yes
No
If yes, please provide the details of the carer below:
Name:
Relationship to patient:
Contact Telephone Number:
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