Referral Form

Complete this form for free support from NHS Bedfordshire Talking Therapies.

It takes around four minutes.

Please note to access our service you must be aged 18 or above and be registered with a GP in Bedfordshire (excluding Luton).

Bedfordshire Talking Therapies is not an urgent crisis service therefore, this referral form should not be used if you require urgent support. If you are worried about immediate risk of harm to yourself or others, please speak to your GP. Alternatively, you can contact the following services 24 hours a day, 7 days a week: NHS 111 and select Option 2 or the Samaritans (116 123).

Talking Therapies do not treat people with diagnoses of bipolar, personality disorder or schizophrenia.

This referral form is not monitored outside of 9-5 Monday to Friday.

What is the main difficulty you would like support with?

If you selected 'Other' please add more information here

If you have a diagnosed long term health condition ie: COPD, diabetes, heart failure that impacts your mental health please specify here

Are you seeking support solely for a drug or alcohol problem?

Yes

No

If you are solely seeking support for a drug or alcohol problem please contact P2R by visiting https://changeyourtomorrow.co.uk/#areas/elft/pages/Home

NHS Number if known

Title*

First Name*

Preferred Name

Last Name*

Preferred Pronouns

What most accurately describes you?*

If 'Person stated self description' is selected, please specify

Date of Birth*

Address Line 1*

Address Line 2

Town/City*

County*

Postcode*

Please state if you would prefer your written communication sent to you by post or email

Post

E-mail

Email

By selecting either post or email you are giving permission for the service to send written communication to you via your preferred option

Main Contact Number*

Alternative Contact Number

Permission to leave voice messages*

Yes

No

Bedfordshire NHS Talking Therapies will be calling from a withheld/private number. We will only leave a message if you have given us permission to do so.

Permission to be contacted by text*

Yes

No

Bedfordshire NHS Talking Therapies use an electronic booking system, by giving permission you allow us to send you a link via text to book your appointment.

Please share the details of someone we can contact in the event of an emergency. We would only ever contact this person if we had concerns about you, in order to help you find the correct immediate support.

Relationship to you ie: next of kin, spouse, friend

First Name*

Last Name*

Telephone Number*

We are striving to support our community and we ask this information to ensure we are inclusive.

Nationality*

Ethnicity*

Religion*

Are you able to communicate in spoken English?*

Yes

No

Are you able to read written English?*

Yes

No

Do you require an interpreter/translator?*

Yes

No

If yes, please state the language you use*

Relationship Status*

Sexual Orientation*

If 'Person stated self description' is selected, please specify

Are you pregnant or do you have a child under 24 months?*

Yes

No

Prefer not to answer

Bedfordshire Talking Therapies offers employment support alongside therapy, this can be to help find work or remain in work. Is this something you would be interested in?*

Yes

No

Have you ever served in the British Armed Forces?*

GP Practice*

By referring yourself to this service you are agreeing that the service may contact and share relevant information with your GP to facilitate your care.

Do you consent to being contacted to help improve our service?

Yes

No

How did you hear about our service?*

Please complete the captcha

Self Referral Form

How Can We Help

Your Details

Address

Contact Details

Emergency Contact Details

Other Personal Details

Registered GP Details