Referral Form

Sheffield IAPT Self Referral Form

* this information is required

Title:*

First Name:*

Last Name:*

Date of Birth:*

Gender:*

Male

Female

Not specified

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

Email address:*

We will send you some questionnaires to compete about your mood before your initial appointment. If you do not wish to receive these by email please contact us to let us know.

GP Surgery:*

How would you describe your Ethnic origin?:*

Main Language Spoken:*

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)

Do you have any Children under the age of 18 living in your household?:*

Yes

No

If relevant, are you:

Currently pregnant?:

Yes

No

Have a child or children under the age of 1?:

Yes

No

Where did you hear about us?:*

If you want to access the online CBT programme called Silvercloud please tick here and we will contact you:

Yes

We have a range of online courses to improve how you feel. We recommend accessing one of courses before 1:1 sessions. Please select which course you would like to attend. All dates of upcoming courses can be found on our website.

Courses:

Overcoming Low Mood

Overcoming Anxiety

Coping with COVID Course (helps with sleep, stress and worry due to COVID pandemic) Thursdays 6-7pm

Stress Control Course Tuesdays 5.30-7pm

None

If you have chosen an Overcoming low mood or anxiety course please specify which time you would prefer. We will book you on to the next available course unless you specify a specific date:

Health and Wellbeing Courses:

If you have not selected to attend one of the courses a member of our team will contact you to book you in for an assessment as soon as possible. Assessments can be by telephone or video call.

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 2003. This is only accessed and used by the IAPT 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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Sheffield IAPT Self Referral Form

How we store your information