Self Referral Form
When you complete this form, our team of advisors will set you up on our system and contact you to arrange for an assessment. This session will help you and the therapist to better understand your difficulties and make a plan for which treatment or service would be most suitable for you. To avoid disappointment please note:
NHS Talking Therapies staff are not trained to work with people with serious mental illness, such as bipolar, psychosis or personality disorder.
NHS Talking Therapies staff are trained in guided self-help and short-term psychological therapies for people with low mood/depression, anxiety disorders and if the Long Term Conditions we work with are impacting on wellbeing.
NHS Talking Therapies services do not provide support for addictions such as gambling, porn, drug or alcohol misuse, anger management or work directly on childhood abuse or complex trauma.
Please speak to your GP if you feel you need support with the above.
We are not a crisis service. If you need immediate help to keep yourself or others safe please call NHS 111, your GP, or go to your local Accident & Emergency department. If you feel yourself or others are at imminent risk of physical harm please call 999.
* = Mandatory Fields
*Do you consent for your GP and other relevant health professionals to be kept up to date with relevant information about your care?
Please Select A Value...
Yes
No
*Do you give us consent to contact you up to 6 months after you have been discharged to invite you to follow up events that we feel may be useful to you? (you can chose to withdraw this consent at any time)
Please Select A Value...
Yes
No
Personal Details
*Title
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
*First Name
*Last/Family Name
*Date of Birth
*Gender
Male (including trans man)
Female (including trans woman)
Non-binary
Other (not listed)
Decline to provide a response
If self described, please specify
*Address Line 1
Address Line 2
*Town/City
County
*Postcode
*Permission to Send Written Communication by Post?
Yes
No
Telephone Number (Home)
Permission to leave Voicemail
Yes
No
Telephone Number (Mobile)
Permission to leave Voicemail
Yes
No
Permission to send text reminders of appointments
Yes
No
Email (if known)
Permission to Contact by Email?
Yes
No
Please provide your NHS Number (if known):
*GP Name
*GP practice
Additional Information
*Nationality
Please Select A Value...
English
Scottish
Welsh
Irish
British
Other
*Ethnicity
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
*Sexuality
Please Select A Value...
Heterosexual
Lesbian or gay
Bisexual
Other
Not stated
*Do you have any disability we should be aware of?
Yes
No
If yes, please select the most appropriate from the list:
Hearing
Manual Dexterity
Memory or ability to concentrate, learn or understand (Learning Disability)
Mobility and Gross Motor
Other
Perception of Physical Danger
Personal, Self Care and Continence
Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits etc)
Sight
Speech
Any other notes relating to your disability:
*Do you have refugee/asylum seeker status?
Yes
No
*Are you able to read and write in English?
Yes
No
*Do you require an interpreter?
Yes
No
If yes, which language is required?
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 suffer with any Long Term Medical Conditions (e.g. Diabetes, Chronic Pain) which affects your day to day life?
Please Select A Value...
Yes
No
Don't Know/Not Sure
If yes, please select
Asthma
Cancer
Chronic Pain, inc Fibromyalgia
COPD
Dementia
Diabetes
Digestive Tract Conditions
Epilepsy
Heart Disease
Long Covid/Post Covid Syndrome
Medically Unexplained Conditions
Musculoskeletal Disorder (MSK)
Neurological Conditions
Other Respiratory Disease
Skin Condition (including eczema)
Other
If Other, please list your conditions here:
*Are you or your partner pregnant or do you have a child under 2?
Pregnant
Child aged under 2
None
Please can you give us the name and contact details of your next of kin:
*Do you look after any dependents, such as children or elderly/disabled family members?
Please Select A Value...
Yes
No
If yes, what are their names, date of birth, and relationship to you:
*Are you an ex-British Armed Forces member?:
Please Select A Value...
Yes
No
About You
*Please provide briefly the reason(s) for your referral. Please could you describe the mental health issue that you would like help with and how it is affecting you?
*Please tell us how you would like to complete your screening assessment:
An online self-assessment with follow up 15 minute phone call
45 minute telephone assessment
NA
Are you available to attend appointments at short notice? (within 24 Hours)
Yes
No
WHAT TO EXPECT: We aim to call you within 24 hours of receiving your referral to book in your assessment.
Once your assessment has been booked, Your therapist will then call you on the mobile number you have provided. Your assessment should take about upto 45 minutes depending on your assessment preference. Please be somewhere you feel comfortable talking for the duration and not driving. This should be confidential space.
If you have provided an email address you will be sent some mood questionnaires to your email inbox in advance of your appointment. Please can you complete these in advance for your therapist to view.
Please specify the times/dates that you CANNOT complete your assessment within the next 7 days in the box below:
*I would like to an assessment to sign up for:
One of your therapy groups/courses
Online self help/CBT modules only
Unsure, full assessment for all options please
All screening assessments are completed over the phone or Teams video call. Your treatment may be remote or face to face following this. If you have specific requirements preventing you from being able to complete an assessment over the phone please write the detail here:
*Are you currently receiving any support (e.g. medication or therapy) for this issue?
Yes
No
*How did you find out about our service?
Please Select A Value...
Social media
Turning Point website
Google search
Attendance at a community event
Recommended by friend/family
Recommended by GP
Recommended by another service
Previously used service
Attended a workshop
Newspaper
Radio
Leaflet/Newsletter
Poster in GP surgery
Have seen service locally
Other
Please provide more detail of where you heard about us:
By completing and submitting this form you are consenting for your information to be stored on our confidential service database. This information is held securely and is not viewed by anyone outside of Turning Point.
Please be aware if you do not give consent, we may still need to speak to other professionals if we feel there is any risk of harm to or from yourself or others, or where a crime has been committed. We would always try to contact you first before making such a decision.
For more details on how your information is stored and shared and other terms and conditions, please visit our Ts and Cs page by copy and pasting this link into another web browser window https://talking.turning-point.co.uk/wakefield/about-us/terms-and-conditions/
*I confirm I have read the Terms and conditions:
Yes
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