Referral Form

Your Details

Title:*

First Name:*

Last Name:*

Gender:*

Male

Female

Not known

Not specified

Date of Birth:*

Address Line 1:*

Address Line 2:

Town/City:*

County:

Postcode:*

Preferred Phone Number:*

Preferred Phone Type:*

Is it ok to leave a voice message on your preferred number?:*

Yes

No

Do you consent to receiving SMS?:

Yes

No

Other Phone Number:

Email address:*

We may need to email you some forms (Web-forms) to complete prior to any assessment with us.

Can we send you our web-forms:

Yes

No

Would you like to nominate an emergency contact?:*

Yes

No

If Yes, please complete the details below.

Full Name:

Telephone Number:

Relationship to you:

GP Surgery:*

If you are unable to find your GP Practice in the list, please contact your GP directly.

GP Telephone Number:

Preferred GP:

Do you have a disability?:*

Yes I have a disability

No I don’t feel I have a disability

I don’t want to say

If you selected yes, please provide details of your disability: this will enable the service to meet any access needs i.e. use of a lift, ensuring wheelchair access, access to BSL, hearing loop access etc.

National identity:*

Ethnicity:*

Religious Group:*

Are you able to communicate in spoken English?:*

Yes

No

Are you able to read and write in English?:*

Yes

No

Do you have another preferred Language: if so please select:

Are you able to read and write in your preferred language?:*

Yes

No

Do you require an Interpreter:*

Yes

No

Relationship Status:*

Sexual Orientation:*

Do you have any of the following Long Term conditions:

Do you have a Medically-Unexplained Condition:

Chronic Fatigue Syndrome/ME

Irritable Bowel Syndrome with diarrhoea

Irritable Bowel Syndrome without diarrhoea

Medically Unexplained Symptoms (not specified)

None of these

Are you currently attending:*

Are you a Military Veteran whose current psychological difficulties are directly related to your military service?:*

If Yes, please provide Service Number:

Are you a parent with caring responsibilities for a child or children under 2, or are you or your partner currently pregnant:*

Yes

No

Are you a Frontline NHS or Health and Social Care member of Staff directly impacted by the Covid response?:*

Yes

No

Have you previously engaged with Secondary Care Mental Health Services? i.e. The Recovery Team, The Home Treatment Team, The Crisis Team, The Assessment Team (Wakefield House), Learning disability services, Dementia Services etc:*

Yes

No

If yes: Which service:

Are you currently receiving support or treatment from any of the above Secondary Care Mental Health Services?:*

Yes

No

If yes: Which service:

If you are currently open to Secondary Care Mental Health Services please liaise with the appropriate team. If therapy is agreed, shared care would need to be discussed and agreed between services.

Are you currently taking any medication for mental your health?:*

Yes

No

If yes, please list:

Please note Talking Matters Warrington is not a crisis intervention service

If you are in crisis or need immediate support please contact the 24/7 mental health crisis line on 0800 051 1508

You can find further information about our service on our website: https://www.mhm.org.uk/talkingmatters-warrington

You can also self-refer by calling the service on 01925 401720

Please complete the captcha

Talking Matters Warrington Self-Referral Form

Your Details

Emergency Contact Details

GP Practice Details

Demographics

Mental Health