Self-Referral Form
Is Talking Therapies the right option for you now?
I need emergency help
We are not a crisis service and not the best service for you if you are very distressed, despairing, or suicidal.
If you need urgent help, there is a freephone telephone line where you can speak to someone who will listen and determine how best to help; the Cornwall 24/7 NHS mental health response line (0800 038 5300) is there for support and advice.
You should dial 999 or go to the Accident and Emergency Department now for immediate help.
I need support for a diagnosed mental health condition
Talking Therapy is not for everyone, and we want to make sure you get the help and support you need. If you are looking for treatment for psychosis, schizophrenia, bi-polar disorder, eating disorders, historical sexual abuse, or complex emotional difficulties, please call Mental Health Connect on 0800 038 5300 for support and advice.
Are you currently receiving support from any other mental health service or professional? *
Yes
No
What’s the main reason for your referral?
We need this information so our therapist can explore with you the best course of treatment during the assessment appointment.
Reasons for referring yourself.
Please choose one option from the drop-down menu that most fits how you are currently feeling.*
Please Select A Value...
Anxiety
Bereavement/Loss
Depressions
Distressing event (trauma)
Health Anxiety
Insomnia
OCD
Social Phobia
Stress
There are different options for treatment, which your therapist can explore with you during your assessment. Please visit www.cornwallft.nhs.uk/talking-therapies/ (copy and paste in to a new window) for more information about these.
If you are interested in a particular option, please indicate here:
Are you are referring because you are the partner of a patient waiting for Couples Therapy for Depression?
Yes
No
Your Details
Title*
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
Mx
First Name*
Last Name*
Preferred name
Preferred Pronouns
Please Select A Value...
She/Her/Her
He/Him/His
They/Them/Their
Ae/Aer/Aer
Ey/Em/Eir
Fae/Faer/Faer
Per/Per/Pers
Ve/Ver/Vers
Xe/Xem/Xyr
Ze/Hir/Hir
Date of Birth*
(Please note if you are under 16 and seeking support, you should contact the Early Help Hub on www.cornwall.gov.uk/earlyhelp)
Gender (as you currently identify)*
Male
Female
Non-binary
Other
Is your gender identity the same as it was at birth? *
Please Select A Value...
Yes
No
Do not wish to say
NHS Number (if known)
Address Line 1*
Address Line 2
Town/City*
County*
Postcode*
How can we contact you?
We like to keep in contact with you at every step of your treatment. This includes appointment arrangements, questionnaires about how you are feeling and your experience of your therapy. Please indicate below how we can contact you.
Home telephone number
Can we leave a voicemail?
Yes
No
Mobile phone number (please enter a number starting with 07 containing no spaces)
Can we leave a voicemail?
Yes
No
Can we send you text messages?
Yes
No
Email address
Can we contact you by email?
Yes
No
Please note, we use your email address, if you have one, to keep in contact with you and send questionnaires about how you are feeling before your initial appointment and throughout your treatment with us. If you do not wish to receive these by email, please email us at cft.talkingtherapiesenquiries@nhs.net or call us on 01208 871905 to let us know.
Emails from our service may go straight into your junk mail or spam folder. The email address our questionnaires comes from is: webforms@myprogress.info please add this email address to your safe list and check your junk/spam folder for any confirmation emails from us.
Do you give us permission to speak to a person you trust (i.e. a relative or a friend) about an appointment booking, rearrangement or cancellation? *
Yes
No
If yes, please specify who and their relationship to you
Emergency contact
Would you like to give us details of someone you would like us to contact in case of an emergency, such as if you fell ill during a therapy session? *
Yes
No
If yes, please specify their name, contact number and relation to you (this can be the same as the trusted contact named above).
GP details
Information from this assessment and your future care is always shared with your GP so they are informed about any treatment you are receiving. To access the NHS Cornwall and the Isles of Scilly Talking Therapies service you need to be registered with a GP in Cornwall. If you are not registered with a Cornish GP, please contact the NHS Talking Therapy service in your GP area.
Name of GP surgery in Cornwall *
GP name (if known)
Further information
We ask the next set of questions to help us check we are doing our best to reach out to everyone in our community.
Religion
Please Select A Value...
No religious group or secular/Atheist
Agnostic
Church of England
Other protestant
Orthodox Christian
Roman Catholic
Other Christian
Muslim
Shi'ite Muslim
Sunni Muslim
Sikh
Jewish
Orthodox Jewish
Buddhist
Hindu
Jain
Parsi / Zoroastrian
Rastafarian
Any other religion
Not stated
Advaitin Hindu
Ahmadi
Amish
Anabaptist
Ancestral Worship
Anglican
Animist
Anthroposophist
Apostolic Pentecostalist
Armenian Catholic
Armenian Orthodox
Arya Samaj Hindu
Asatruar
Ashkenazi Jew
Atheist
Baha'i
Baptist
Black Magic
Brahma Kumari
Brethren
British Israelite
Bulgarian Orthodox
Calvinist
Catholic: Not Roman Catholic
Celtic Christian
Celtic Orthodox Christian
Celtic Pagan
Chinese Evangelical Christian
Chondogyo
Christadelphian
Christian Existentialist
Christian Humanist
Christian Scientists
Christian Spiritualist
Church in Wales
Church of God of Prophecy
Church of Ireland
Church of Scotland
Confucianist
Congregationalist
Coptic Orthodox
Deist
Druid
Druze
Eastern Catholic
Eastern Orthodox
Elim Pentecostalist
Ethiopian Orthodox
Evangelical Christian
Exclusive Brethren
Free Church
Free Church of Scotland
Free Evangelical Presbyterian
Free Methodist
Free Presbyterian
French Protestant
Goddess
Greek Catholic
Greek Orthodox
Haredi Jew
Hasidic Jew
Heathen
Humanist
Independent Methodist
Indian Orthodox
Infinite Way
Ismaili Muslim
Jehovah's Witness
Judaic Christian
Kabbalist
Liberal Jew
Lightworker
Lutheran
Mahayana Buddhist
Masorti Jew
Mennonite
Messianic Jew
Methodist
Moravian
Mormon
Native American Religion
Nazarene Church / SYN Nazarene
New Age Practitioner
New Kadampa Tradition Buddhist
New Testament Pentacostalist
Nichiren Buddhist
Nonconformist
Occultist
Old Catholic
Open Brethren
Pagan
Pantheist
Pentecostalist / SYN Pentacostal Christian
Peyotist
Plymouth Brethren
Presbyterian
Pure Land Buddhist
Quaker
Radha Soami / SYN Sant Mat
Reform Jew
Reformed Christian
Reformed Presbyterian
Reformed Protestant
Romanian Orthodox
Russian Orthodox
Salvation Army Member
Santeri
Satanist
Scientologist
Scottish Episcopalian
Secularist
Serbian Orthodox
Seventh Day Adventist
Shakti Hindu
Shaman
Shinto
Shiva Hindu
Shumei
Spiritualist
Swedenborgian / SYN Neo-Christian
Syrian Orthodox
Taoist
Theravada Buddhist
Tibetan Buddhist
Ukrainian Catholic
Ukrainian Orthodox
Uniate Catholic
Unitarian
Unitarian-Universalist
United Reform
Universalist
Vaishnava Hindu / Hare Krishna
Vodun
Wiccan
Yoruba
Zen Buddhist
Zwinglian
Nationality
Please Select A Value...
British
English
Irish
Scottish
Welsh
Other
Have you ever served in the armed forces? *
Please Select A Value...
No
Yes - ex services
Yes - currently serving
Dependant of a ex-serving member
Not stated (Person asked but declined to provide a response)
Unknown (Person asked and does not know or isn't sure)
Relationship status
Please Select A Value...
Single
Married
Divorced
Widowed
Separated
Co-Habiting
Long term
Civil Partnership
Not Disclosed
Sexuality*
Please Select A Value...
Bisexual
Gay (female)
Gay (male)
Heterosexual
Other
Not known
Not stated
Ethnicity*
Please Select A Value...
Asian or Asian British - Any other Asian background
Asian or Asian British - Bangladeshi
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Black or Black British - African
Black or Black British - Any other Black background
Black or Black British - Caribbean
Mixed - Any other mixed background
Mixed - White and Asian
Mixed - White and Black African
Mixed - White and Black Caribbean
White - Any other White background
White - British
White - Irish
Other Ethnic Groups - Any other ethnic group
Other Ethnic Groups - Chinese
Not known - Not known
Not Stated - Not Stated
We support people with a wide range of needs so answering these questions will help us to understand how we can best support you.
Will you require an interpreter? *
Yes
No
Language required
Please Select A Value...
Akan (Ashanti)
Albanian
Amharic
Arabic
Bengali & Sylheti
Brawa & Somali
British Sign Language
Cantonese (Chinese)
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 (Chinese)
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
To help us to support you to access the service, can you let us know if any of the following apply to you? *
Learning Disability
Hearing Impairment
Visual Impairment
Mobility Issues
Difficulties with reading and/or writing
Other (you can share further information with your therapist during your assessment)
None
Do any of these apply? *
Pregnant or partner is pregnant
Parent of a baby 12 months or less
Lost a pregnancy or baby within the last 12 months
None
Please give us information on any disabilities (physical or learning) and any long-term medical conditions. We offer a specific service for people diagnosed with the following long-term conditions - (diabetes, cardio-vascular disease, COPD and IBS). In addition, telling us about any other medical conditions, will help your therapist understand more about you.
Please tick all that apply
Arthritis
Asthma
Cancer
Cardiovascular disease/ heart failure
Chronic Fatigue/ ME
Chronic Muscular Skeletal condition
Chronic Obstructive Pulmonary Disease (COPD)
Chronic Pain - arising from an identified medical condition
Chronic Pain - with no medical explanation (e.g. non cardiac chest pain, chronic pelvic pain, atypical face pain)
Dementia
Diabetes
Dizziness
Epilepsy
Fibromyalgia
Functional Neurological Symptoms (e.g. non epileptic seizures, blackouts, functional weakness, functional blindness)
Globus syndromes (i.e. swallowing)
Irritable bowel/bladder syndrome
Lupus
Multiple Sclerosis (MS)
Premenstrual syndrome
Rheumatoid Arthritis
Sickle Cell Anaemia
Stroke
Tension headaches
Other (you can share further information with your therapist during your assessment)
What Happens Next?
Within 5 working days of receiving your referral, you will be contacted by a member of our admin team to arrange your initial telephone assessment appointment with one of our therapists. Once confirmed, your appointment details will be emailed or posted to you and will include further information about what to expect.
There may be times when we would need to discuss transferring your care with other services if we are not the
appropriate
service to meet your needs. If you do not hear from us after 5 days, please feel free to contact us on 01208 871905 or email cft.talkingtherapiesenquiries@nhs.net
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 Data Protection Act 2018 and UK General Data Protection Regulation (UK GDPR).
The information you provide on this form and during your care will be used to document, monitor and plan your treatment. We will share information with other health care professionals for the purpose of direct care to ensure continuity of care and that the treatment provided is appropriate to your needs.
For further information please copy this link into a new tab: www.cornwallft.nhs.uk/privacy-notice-patients
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