Referral Form

To refer yourself to the BaNES Talking Therapies service please complete and submit the form below. To be eligible you must be:

• Aged 16 years and over

• Registered with a GP in BaNES

We are best placed to help you if your main problem is low mood, stress or anxiety difficulties. If you are experiencing more chronic and enduring mental health or substance misuse issues you could benefit from seeing your GP before making a self-referral to us to help you choose the most appropriate service for your needs.

BaNES Talking Therapies is not an urgent or crisis service so if you are worried about immediate risk of harm to yourself or others, please speak to your GP. Alternatively, call AWP’s 24 hour urgent response line free on 0800 953 1919 or for someone to talk to, contact The Samaritans for free on 116 123.

We take confidentiality very seriously. The form is fully secure and all details you provide will be stored on our confidential patient information management system.

Please note, fields marked with an asterisk * must be completed

Everyone registered with the NHS in England and Wales has their own unique id number. It can be found on any letter or document you have received from the NHS, such as prescriptions, test results, and appointment letters. Please enter it here as 10 digits with no spaces.

NHS Number (if known):

Title:*

First Name(s):*

Surname:*

Please note that we are only able to accept your referral if you are aged 16 or over.

Date of Birth:*

Gender:*

Is your gender the same as that assigned at birth?:*

Preferred Pronouns:

Relationship Status:*

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Email:*

By giving us your email address, you are consenting to us sending you emails. If you do not have an email address, please input the following: noemail@nhs.net.

Please note: We will use your email address to send you further details about your assessment appointment and some questionnaires to complete about your mood before your appointment. If you do not wish to receive these by email, please contact us to let us know.

Emails from our service may go straight in to your junk mail or spam folder. The email address our questionnaires come from is: 'webform@myprogress.info' please can you add this address to your safe list and check your junk/spam folder for any confirmation emails from us.

Mobile Number:

This is an essential contact number for any cancellations.

Can we leave voicemails?:

Yes

No

Can we send texts to this number?:

Yes

No

Home Telephone Number:

Can we leave voicemails?:

Yes

No

Work Number:

Can we leave voicemails?:

Yes

No

Named GP (if known):

GP Surgery Name:*

We will always contact your GP or other relevant agencies in order to keep yourself or others safe.

We collect this information because we know that different groups experience healthcare inequalities and we want to make sure that we are finding where these gaps are and delivering best practice where we can.

Ethnicity:*

Sexual orientation:*

Do you have any of the following Long term Health Conditions?:*

If Other, please state:

Do you have a disability that we need to be made aware of?:*

Yes

No

If Yes, please specify:

Ex-British Armed Forces or dependant of an ex-serving member?:*

Religious or Belief Affiliation:*

Please let us know if you are (tick all that apply):*

Preferred Language:*

Are you able to communicate in English?:

Yes

No

Please detail any accessibility requirements (e.g. interpreter required, information in large print, wheelchair user etc.):

What is your employment status?:*

Are you currently receiving sick pay?:*

Have you previously accessed our service?:

Yes

No

Are you currently receiving support for your mental health?:*

Yes

No

If Yes, please give details:

Are you currently taking any prescribed medication for your psychological wellbeing?:*

Yes

No

Once we have reviewed your application and confirmed your eligibility, we will aim to be in touch within the next 5 working days to arrange your assessment appointment.

Please complete the captcha

Self-Referral Form

Your Details

Your GP Details

About You

Referral Information

What happens next?