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?

*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)

*Title

*First Name

*Last/Family Name

*Date of Birth

*Gender

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

*Nationality

*Ethnicity

*Sexuality

*Do you have any disability we should be aware of?

Yes

No

If yes, please select the most appropriate from the list:

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?

*Do you suffer with any Long Term Medical Conditions (e.g. Diabetes, Chronic Pain) which affects your day to day life?

If yes, please select

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?

If yes, what are their names, date of birth, and relationship to you:

*Are you an ex-British Armed Forces member?:

*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 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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Self Referral Form

Personal Details

Additional Information

About You