Self Referral Form
Sheffield IAPT Self Referral Form
* this information is required
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
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.
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 Surgery:*
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
Main Language Spoken:*
Please Select A Value...
Akan (Ashanti)
Albanian
Amharic
Arabic
Bengali & Sylheti
Brawa & Somali
British Signing Language
Cantonese
Cantonese and Vietnamese
Creole
Dutch
English
Ethiopian
Farsi (Persian)
Finnish
Flemish
French
French creole
Gaelic
German
Greek
Gujarati
Hakka
Hausa
Hebrew
Hindi
Igbo (Ibo)
Italian
Japanese
Korean
Kurdish
Lingala
Luganda
Makaton (sign language)
Malayalam
Mandarin
Norwegian
Pashto (Pushtoo)
Patois
Polish
Portuguese
Punjabi
Russian
Serbian/Croatian
Sinhala
Somali
Spanish
Swahili
Swedish
Sylheti
Tagalog (Filipino)
Tamil
Thai
Tigrinya
Turkish
Urdu
Vietnamese
Welsh
Yoruba
Other
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)
Respiratory
Heart Disease
Musculoskeletal (MSK)
Chronic Pain including Fibromyalgia
Epilepsy
Skin condition including Eczema
Digestive tract systems
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?:*
How we can help you
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
Improving Wellbeing in the COVID-19 Pandemic (helps with sleep, stress and worry) Thursday 1-2pm
Stress Control Course Tuesdays 5.30-7pm
Stress Control Course Thursday 5.30-7pm
Arabic عربي Wellbeing Sessions (women only) January 12th 10-12pm
Urdu اردو Wellbeing Sessions (women only) March 2nd 10-12pm
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:
Monday 2-3.30pm
Tuesday 10-11.30am
Tuesday Evening 5.30-7.00pm
Wednesday 10-11.30am
Wednesday 4.30-6pm
Thursday Evening 5.30-7.00pm
Friday 10-11.30am
Friday of 2-3.30pm
Health and Wellbeing Courses:
Managing Health Worries
Living Well with Fatigue
Living Well with a Long Term Condition
Big Pain Course
First Steps to Mindfulness
Living well with IBS
Living well with Diabetes
None
If you have not selected a course option. Please tick here to receive the following: (Only select one of these options if you have NOT selected a course)
Telephone assessment with one of our Psychological Wellbeing Practitioners
Access the online CBT programme called Silvercloud
None
If you selected a telephone assessment, the purpose of that assessment will be to clearly understand how you are feeling and help to advise you on the range of treatment options available to help you. A member of our team will contact you to book this for you soon as possible.
How we store your information
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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