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

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.*

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

Title*

First Name*

Last Name*

Preferred name

Preferred Pronouns

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? *

NHS Number (if known)

Address Line 1*

Address Line 2

Town/City*

County*

Postcode*

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

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).

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)

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

Nationality

Have you ever served in the armed forces? *

Relationship status

Sexuality*

Ethnicity*

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

To help us to support you to access the service, can you let us know if any of the following apply to you? *

Do any of these apply? *

Pregnant or partner is pregnant

Parent of a baby 24 months or less

Lost a pregnancy or baby within the last 24 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

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

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

Are you willing to be contacted to participate in research? *

Yes

No

Where did you hear about us?

Please complete the captcha

Self-Referral Form

Is Talking Therapies the right option for you now?

What’s the main reason for your referral?

Your Details

How can we contact you?

Emergency contact

GP details

Further information

What Happens Next?

How we store your information