Referral Form

Sheffield IAPT 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 IAPT service covers your area, please either use this link https://www.nhs.uk/Service-Search/Psychological therapies (IAPT)/LocationSearch/10008 or arrange to speak to your GP.

Sheffield IAPT 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

IAPT staff are not trained to work with people with serious mental illness, such as bipolar or personality disorder.

IAPT 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.

IAPT 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 IAPT 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

Title:*

First Name:*

Last Name:*

Date of Birth:*

Gender:*

Address Line 1:*

Address Line 2:

Town/City:*

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:*

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 Name:

GP Surgery:*

How would you describe your Ethnic origin?:*

What is your preferred spoken language?:*

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)

If other, please state:

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)

Are you an ex-British Armed Forces member?*

Where did you hear about us?:*

What is the main problem you are seeking help for?:*

Preferred Treatment Option:*

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

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 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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Self Referral Form

Sheffield IAPT Self Referral Form

Referral

Your details

GP Details

Further information

How we can help you

What will happen next

How we store your information