DHC Talking Therapies GP/Professional Patient referral form
Referrer Details
GP Name:*
GP Surgery:*
Referrer Name if not GP:*
Role:*
Phone number:*
Email address:*
Patient Details
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Mx
Dr
Rev
Prof
First name:*
Preferred name:
Last name:*
Date of Birth:*
Gender:*
Male
Female
Non binary
Not known
Not specified
NHS Number:
Address Line 1:*
Address Line 2:
Town:*
Postcode:*
Please leave at least one contact number.
Home Number:
Can we leave a message on this number?:
Yes
No
Mobile Number:
Can we leave a message on this number?:
Yes
No
SMS allowed?:
Yes
No
Email address:
Disability status:
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
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 background
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
Lesbian or gay
Bisexual
Other
Not known
Not stated
Are there Long Term Conditions? If yes, please provide details:
Ex-British Armed Forces:
Please Select A Value...
Yes - ex services
No
Dependant of a ex-serving member
Unknown (Person asked and does not know or isn't sure)
Not stated (Person asked but declined to provide a response)
Is the person in the perinatal period?:
Yes
No
Has the patient consented to this referral?:*
Yes
No
Is the person an unpaid Carer or have a Carer?:
Yes
No
If yes, please give details including any access needs:
Presenting Problem
Please give brief reason for referral:*
Does the client have current or past involvement with other mental health services?:*
Yes
No
If known, please specify dates & nature of treatment:
Has the Client been diagnosed with any severe and enduring mental health condition? (E.g: Psychosis/ Schizophrenia/ Bi polar):*
Yes
No
If yes, please provide details:
Is the Client prescribed any medications for current symptoms of depression or anxiety?:*
Yes
No
If yes, please provide details:
RISK: Is there any current risk to self or to others?:*
Yes
No
If yes- what is the risk and what Risk Management Plan is in place:
Will you be providing any ongoing support/care to the client? If yes, please give details:*
Please send any additional information or documents to us via email to iapt.dhc@nhs.net
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