Referral Form

If you are registered with a Newcastle GP and would like to refer yourself, please complete the online form below or telephone or email using the following contact information.

Tel: 0191 2826600 Email: refer@talkinghelpsnewcastle.org (Please be advised that email contact cannot be guaranteed as secure)

We will contact you by your preferred method within 3 working days. If you do not hear from us within this time frame please call us on 0191 2826600.

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

This online referral form is fully secure and all details below will be stored on our secure and confidential system. Please note, by completing this form you agree to these terms.

Title:*

First Name:*

Surname:*

Date of Birth:*

Gender:*

Male

Female

Not known

Not specified

Address line 1:*

Address line 2:

Town:*

County:*

Postcode:*

NHS Number (if known):

Ethnicity:*

Religious Group:*

Relationship Status:*

Sexual Orientation:*

Please indicate your preferred method of contact from us:*

Please let us know the best times for one of our therapists to contact you for an initial telephone appointment.

Preferred Contact Day(s):

Preferred Contact Time(s):

AM

PM

Anytime

If we are unable to contact you by phone or leave a message we will write to you.

Home Phone:

Can we leave a message?:

Yes

No

Mobile Phone:

Can we leave a message?:

Yes

No

Can we send you SMS Text appointment reminders?:

Yes

No

Email:*

Confirm Email:*

Your Surgery:*

GP Name (if known):

Please give us a brief description of why you would like to be seen in our service.

Reason for referral:*

Please note, a telephone translator and interpreter service is available – please indicate below if this is required and the language you would prefer to use. We will then arrange for an interpreter to be available when we contact you.

Do you require an interpreter?:

Yes

No

If yes, please state the language you require:

Are you being seen by other services?:

Yes

No

If yes, then please state:

Do you have a disability?:

Do you have a long term health condition?:

If yes, then please state:

Have you served in the British Army or are you a dependent of an ex-serving member?:*

Are you pregnant or have you given birth in the last 12 months?:

Yes

No

Thank you for completing this form. Before pressing the submit button below, please ensure you have entered all the relevant characters into the white box in the captcha (please note they are case sensitive and there are often two words required separated by a space). Once you press the submit button, please wait until you receive the green success message. If you do not see this, please review your form as it may require amendments or there may be an incomplete mandatory field.

Thank you for contacting our service, we will be in touch soon.

Please complete the captcha

Online Referral Form

Your Information

Contact Details

GP Details

Referral Information

Other Information

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