Referral Form

If you need immediate support please call your GP or go to your local Accident & Emergency department. For more information on accessing urgent help please see https://www.icope.nhs.uk/camden-islington/crisis-support/

Please provide as much information as possible to help us process your referral quickly. We offer a range of short-term, goal-focused psychological interventions for people who are looking to make changes in their lives. If you are unsure if our service is the right service for you or if you have any problems completing this online form, you can call us to discuss this.

Please be aware that the information you share with us is kept confidential. However, if you share information concerning current or potential harm to yourself or another person, it is likely that we will need to inform other agencies to ensure that the right support is provided. We would always try to contact you first to discuss this.

We routinely share information with your GP and other NHS providers about your referral and treatment, which we may do either verbally or in writing. When we receive a referral we may look on Trust or GP notes to make sure we are the most suitable service for you. For more information about confidentiality and data sharing please see: https://www.icope.nhs.uk/camden-islington/helpful-resources/information-sharing-and-confidentiality/ or view our FAQs on the website. If you have concerns about information sharing please discuss them with us.

Title:*

First Name:*

Last Name:*

You can only refer yourself to us if you are over 18

Date of Birth:*

Address Line 1:*

Address Line 2:

Town:*

County:

Postcode:*

Mobile Number:*

Permission to leave voicemails:*

Yes

No

Permission to contact by text:*

Yes

No

Other Number:

Can we leave voicemails on this number?:

Yes

No

Email:*

By providing us with this information we will assume that you consent to be contacted in this way.

Do you need an interpreter?:

Yes

No

If yes, please specify your language:

We only see people with a GP in Camden or Islington or who live in Camden and Islington. We ask for your GP details so we can contact them about your care if needed. We may check your NHS records held by your GP or other NHS Providers where we need further information to help us provide you with the best possible care.

Do you have a GP in Camden or Islington or live in Camden or Islington?*

Yes, I have a GP in Camden or live in Camden

Yes, I have a GP in Islington or live in Islington

GP Practice:*

Please let us know if there is anyone you would like us to contact in the event of an emergency.

Name:

Contact Number:

Relationship to you:

Please note we would only use this information in the event of an emergency

We ask these questions to ensure that our service is being accessed by everyone and to ensure any specific requirements are met.

Ethnicity:*

Sexuality:*

Gender:*

Preferred pronoun

If other, please specify

Do you have any long term medical conditions?:*

If Other, please specify:

Is the main reason for this referral related to your long-term health condition(s)?*

Yes

No

Do you have any disabilities you would like us to be aware of?:*

If Other, please specify:

Are you an NHS or social care front line worker?:

Yes

No

Are you, or your partner, pregnant or do you have any children under 1 or under 2?:*

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

Are you receiving counselling, therapy or other mental health support elsewhere?:*

Yes

No

Unsure

If yes, please provide further details:

Please describe the problem you need help with:*

What type of help are you looking for from iCope:*

In our service we continually try to better understand and support people with mental health problems. Would you be willing to be contacted about participating in research which helps us do that? Please note that all our research studies hold to the highest standards of confidentiality and data security.

Yes, I am happy for a researcher affiliated with iCope to contact me about a research study being run in the service. I understand that agreeing to this will have no effect on the treatment I receive in iCope and I can withdraw my consent at any time.

No, I do not wish to be contacted about research studies

Where did you hear about us?*

If other, please specify:

Thank you for taking the time to complete this form. Please note, you will not receive any email confirmation after submitting this form but we will be in touch with you as soon as possible.

Please complete the captcha

Self Referral Form

Your Information

Your Details

GP Details

Emergency Contact

Further Information