North Tyneside Talking Therapies Self Referral Form

Registering Your Details

If you have answered NO to Q2, please do not proceed with this referral:
- Ring the Mental Health Crisis Team on 0303 123 1146 (available 24 hours per day).
- Attend the emergency department at your local hospital.

Working With Other Services

Please note: If you have been supported by any of the following mental health services within the timeframes stated, or are still supported by them, please do not continue with this referral; contact that service or your GP. We will require a healthcare professional referral from them to ensure the best service is meeting your needs.
• Mental Health Crisis Team and/or Emergency department at your local hospital (within one month)
• Drug and Alcohol Services (within 6 months)
• Community Treatment Team or Community Mental Health Team (within 12 months)
• Child and Adolescent Mental Health Services (within 6 months)

My Details

Next of kin/emergency contact

Further Information

Your Mental Health And Wellbeing

Life Experiences

Your Physical Symptoms

Your thoughts

Things that you do

Current Mental Health

Previous Mental Health

Now we need to look at how often you’re experiencing these symptoms. We do this using the following brief questionnaire.

PHQ9

Over the last 2 weeks, how often have you been bothered by any of the following problems?
PHQ-9 is adapted from PRIME MD TODAY, developed by Drs Robert L. Spitzer, Janet B.W. Williams, Kurt Kroenke, and colleagues, with an educational grant from Pfizer Inc. For research information, contact Dr Spitzer at rls8@columbia.edu. Use of the PHQ-9 may only be made in accordance with the Terms of Use available at http\//www.pfizer.com. Copyright 1999 Pfizer Inc. All rights reserved. PRIME MD TODAY is a trademark of Pfizer Inc.

GAD7

Over the past 2 weeks, how often have you been bothered by any of the following problems?
The GAD-7 originates from Spitzer RL, Kroenke K, Williams JB, et al; A brief measure for assessing generalized anxiety disorder\ the GAD-7. Arch Intern Med. 2006 May 22;166(10)\1092-7. GAD-7 © Pfizer Inc. all rights reserved; used with permission.

Work & Social Adjustment

People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems look at each section and determine on the scale provided how much your problem impairs your ability to carry out the activity.
Ref: Mundt, J. C., I. M. Marks, et al. (2002). "The Work and Social Adjustment Scale: a simple measure of impairment in functioning." Br J Psychiatry 180: 461-4.

Phobia Scales

Choose a number from the scale below to show how much you would avoid each of the situations or objects.
The IAPT Phobia Scale is reproduced from the IAPT Toolkit which is ©Crown copyright. Reproduced under the terms of the Open Government Licence which can be found at http://www.nationalarchives.gov.uk/doc/open-government-licence/version/1/open-government-licence.htm

Medication, Physical Health Conditions And Lifestyle Factors

Although we cannot provide medication in our service, it’s important that we have information about what you are taking.

Physical health conditions

We recognise that sometimes people's physical health conditions impact their mental health, and vice versa. If you told us earlier about any long-term physical health condition(s), please answer the following

Lifestyle factors

Life circumstances can impact on mental health too.

Your Living Circumstances

Alcohol And Substances

Sometimes, people try to manage their difficulties by drinking or using illicit substances. This may seem to help in the short term however longer term they tend to make anxiety and depression worse.

Your Patient Experience

We are required to report anonymised data on referral and treatment information to the Department of Health in order to monitor standards of care. Your personal information is automatically removed when data is reported and held securely and handled in accordance with the Data Protection Act.
I understand the information supplied within this referral form will be stored securely and confidentially by Northumbria Healthcare NHS Foundation Trust in a patient management system held by North Tyneside Talking Therapies. I understand that my data will not be shared without my consent, UNLESS, there are concerns for the safety or myself or others (including children).

What Happens Now?

A member of our team will review the information you have provided. After this, you will be contacted by telephone to discuss next steps.
It may be that this is not the most appropriate service to help you. If this is the case, we may be able to recommend other local services that better suit your needs.
Thank you for completing the online assessment. It can take a lot of courage to reach out, and even more to share.