Self Referral Form
Sheffield Talking Therapies Self Referral Form
Please note to access our service you must be aged 18 or above and will need to either be a resident or be registered with a GP in Sheffield or have a Sheffield Consultant if you are accessing our Health and Wellbeing Service.
If you are unsure which Talking Therapies service covers your area, please either use this link https://www.nhs.uk/service-search/mental-health/find-an-nhs-talking-therapies-service or arrange to speak to your GP.
Sheffield Talking Therapies is not an urgent or 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 also contact the following services 24 hours a day, 7 days a week: Single Point of Access (0808 196 8281), NHS Helpline (111), and the Samaritans (116 123).
This referral form is not monitored outside of 9-5pm Monday to Friday.
Please confirm that you understand the above information:*
Yes
* this information is required
Referral
Talking Therapies staff are not trained to work with people with serious mental illness, such as bipolar or personality disorder.
Talking Therapies staff are trained in guided self-help and short-term therapy for people with low mood/depression, anxiety disorders and if the Long Term Conditions we work with are impacting on wellbeing.
Talking Therapies services do not provide support for drug or alcohol misuse, anger management or work directly on childhood abuse or complex trauma.
Please indicate whether this is a:*
Referral for yourself
Referral from a Health Care Professional
If Health Care Professional, please specify below:
GP/Practice nurse
STH Consultant/Team
Other health care professional
If Voluntary Sector, please specify:
If Talking Therapies was recommended by a health care professional or you are a health care professional referring this person please can you tell us:
Referrer name:
Referrer Professional Role:
Referrer's team/service (eg STH Diabetes Service, STH Tinnitus Service or GP):
Referrer email:
Are you currently under the care of Sheffield Teaching Hospitals?:*
Yes
No
Your details
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
Mx
First Name:*
Last Name:*
Date of Birth:*
Gender:*
Male
Female
Non-binary
Other
Prefer not to say
Address Line 1:*
Address Line 2:
Town/City:*
County:*
Postcode:*
Home Phone Number:
Do you give consent for us to leave a message on this number? This consent will include if another person answers your phone.
Yes
No
Mobile Phone Number:
Do you give consent for us to leave a message on this number? This consent will include if another person answers your phone.
Yes
No
Would you like us to send you SMS Text Reminders for Appointments?:
Yes
No
If you do not have a phone number for our team to contact you, please phone them on 0114 2264380 to arrange a referral.
Email address:*
Please note: We use your email address to confirm appointments only. If you do not have an email address, please input the following: noemail@nhs.net
We will send you some questionnaires to complete about your mood before your initial appointment. If you do not wish to receive these by email please contact us to let us know.
Emails from our service may go straight in to your junk mail or spam folder. The email address our questionnaires comes from is: 'webform@myprogress.info' please can you add this email address to your safe list and check your junk/spam folder for any confirmation emails from us.
GP Details
GP Name:
GP Surgery:*
Further information
What is your sexual orientation?*
Please Select A Value...
Heterosexual
Lesbian or gay
Bisexual
Other
Not known
Not stated
Unknown
How would you describe your Ethnic origin?:*
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
Not known - Patient Declined
What is your preferred spoken language?:*
Please Select A Value...
Akan (Ashanti)
Albanian
Amharic
Arabic
Bengali & Sylheti
Brawa & Somali
British Signing Language
Chinese
Dutch
English
Farsi (Persian)
Finnish
Flemish
French
Gaelic
German
Greek
Gujarati
Hausa
Hebrew
Hindi
Hungarian
Igbo (Ibo)
Italian
Japanese
Korean
Kurdish Badini
Kurdish Hawrami
Kurdish Kurmanji
Kurdish Sorani
Lingala
Luganda
Makaton (sign language)
Malayalam
Mandarin
Norwegian
Pashto (Pushtoo)
Polish
Portuguese
Punjabi
Romanian
Russian
Serbian/Croatian
Sinhala
Slovak
Somali
Spanish
Swahili
Swedish
Tagalog (Filipino)
Tamil
Thai
Tigrinya
Turkish
Urdu
Vietnamese
Welsh
Yoruba
Do you require an interpreter or help with Communication:*
Yes
No
Additional information e.g. BSL Interpreter:
Do you consider yourself to have a disability?:*
Yes
No
If Yes, please give details about your disability:
Do you have any of the following long term conditions? (tick any that apply)
Asthma
Diabetes
Chronic Obstructive Pulmonary Disease (COPD)
Heart Disease
Musculoskeletal (MSK)/Chronic Pain
Skin condition including Eczema
Irritable Bowel Syndrome (IBS)
Tinnitus
Long COVID
Fatigue
CFS/ME
Persistent Physical Symptoms/Medically Unexplained Symptoms
Other (please specify below)
Other long term conditions:
Do you have any Children under the age of 18 living in your household?:*
Yes
No
To make our service accessible to your needs, please let us know if you are: (tick all that apply)
Pregnant
Partner pregnant
Family with child under one year
Family with child under two years
Family with children under one year
Family with children under two years
Are you an ex-British Armed Forces member?*
Please Select A Value...
Yes - ex services
No
Dependant of a ex-serving member
Are you currently a student?
Yes
No
Where did you hear about us?:*
Please Select A Value...
Billboard advertisement
Facebook
Google
GP
Talking Therapies Website
Instagram
Leaflet
Local magazine
Poster
Promotional stall
Radio
SHSC Website
Twitter
Wellbeing session
YouTube Advert
Other
How we can help you
What is the main problem you are seeking help for?:*
Please Select A Value...
Anxiety
Depression
Feeling down
Feeling fed up
Feeling worried
Health anxiety
Long-term condition impacting on wellbeing
Low mood
OCD
PTSD
Social anxiety
Stress
Translated wellbeing sessions
Preferred Treatment Option:*
Please Select A Value...
Managing Stress Tuesday 5.30pm – 7pm (course)
Managing Stress Thursday 5.30pm – 7pm (course)
Improving Wellbeing Sessions for Anxiety (course)
Improving Wellbeing Sessions for Depression (course)
Arabic عربي Anxiety Wellbeing Sessions (women only) Tues 10-12pm
Arabic عربي Low Mood Wellbeing Sessions (women only) Tues 10-12pm
Urdu اردو Anxiety Wellbeing Sessions (women only) Tues 10-12pm
Urdu اردو Low Mood Wellbeing Sessions (women only) Tues 10-12pm
Managing Health Worries course
Living Well with Fatigue course
Living Well with a Long Term Condition course
Living Well with Long Term Pain Course
Online CBT programme (Silvercloud)
Telephone assessment with a Psychological Wellbeing Practitioner
Managing Wellbeing around Christmas
Mindfulness Based Cognitive Therapy (MBCT) Course for Depression
Mindfulness for Health Course (for living with a health condition)
What will happen next
If you have selected one of our courses on this self-referral form, you will be invited to book an assessment call first with one of our Psychological Wellbeing Practitioners. This will allow you to find out some more information about the course and make sure it is the right treatment for you. You will receive a link via text message to choose a day and time that is convenient for your call.
If you have selected a telephone assessment with a Psychological Wellbeing Practitioner, or you would like to access our online programme Silvercloud, you will receive a link via text message to choose a day and time that is convenient for your call.
If we feel another service would be more suitable to help you at this time, you will be contacted by a member of our duty team to discuss this further with you
How we store your information
In taking your details, we recognise the importance of personal privacy and make sure all information about you is held securely in accordance with the General Data Protection Regulation (GDPR)
This service keeps the information that you share on a dedicated computer system to ensure it is stored safely and securely under the Data Protection Act 2018. This is only accessed and used by the Talking Therapies team to plan and monitor your treatment. We may also want to share information with other professionals who need to be involved in your care to ensure that you receive the correct treatment at the right time and we will ask your permission to do this.
On occasions we may need to share information with other professionals without your permission if we are concerned about your safety, the safety of another person, or you inform us that you have/or are about to, commit a serious crime. Should this be the case we will always try to discuss this with you first and involve you in the process. For more information please read our information storing leaflet on our website.
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