Self Referral Form for Deaf People
Important Information - We are not a crisis service
If you feel suicidal or want to self-harm - please contact your doctor Urgent, or contact NHS 111, or go to Accident & Emergency department at Hospital or text DEAF to 85258 for free and immediate support from SHOUT.
Your Details
Title:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Dr
Rev
Prof
First Name:*
Last Name:*
Address Line 1:*
Address Line 2:
Town:*
County:
Postcode:*
Gender:*
Male
Female
Transgender Male
Transgender Female
Non Binary
Prefer not to answer
Mobile/SMS Number:*
Do you consent for us to contact you by text?*
Yes
No
Do you consent for us to contact you by email?:*
Yes
No
Are you Deaf/deaf and able to communicate in BSL or SSE?:*
Yes
No
Email:
BSL User:*
Please Select A Value...
British Sign Language
Deaf/Blind
Lip reader
SSE
Date of Birth:*
NHS Number:
Online Therapy - have internet at home?
Yes
No
Do you have a:
Laptop
PC
Tablet
What do you use for Video Calls:
WhatsApp
FaceTime
Zoom
Something else please advise below
Something else, please state here:
What days are best for Video Therapy Appointments – Monday to Friday only. Please state:
GP Details
Doctor’s Name:*
Doctor’s Surgery Address:*
There may be situations when this NHS service from SignHealth may need to contact your GP as we have a duty to ensure you receive the appropriate service, request funding for your therapy, or address serious safety risks to yourself or others.
Do you agree for SignHealth to contact your GP or local NHS?:*
Yes
Do you agree for SignHealth Psychological Therapy to contact the funding commissioning department at your local Integrated Care Board if Funding is required:*
Yes
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
Referral Information
IMPORTANT We are not a crisis service
If you feel suicidal or want to self-harm - please contact your doctor urgently, or contact NHS 111, or go to Accident & Emergency department at Hospital or text DEAF to 85258 for free and immediate support from SHOUT.
Your problem - please indicate:*
Depression/feeling low
Problems with work
Complex bereavement/grief/death
Physical health problems
Anxiety/stress
Phobia
Panic
Relationship/family problems
Extra comments:
Have you had this problem before? If yes, when?:
Have you had counselling/therapy in the past?:*
Yes
No
If yes, what?
One to one therapy in BSL
Therapy using BSL interpreter
One to one therapy with no BSL i.e. write, try to lip read
Refused to go to therapy with BSL interpreter
And where/who with?
How did you find out about SignHealth Psychological Therapy Service?:*
Doctor
Other Professional
Friend
Website
Facebook
Other
If other, please specify:
By completing this form and pressing submit, your details will be stored on our secure confidential system in accordance with the Data Protection Act 2018.
We will be in touch within the next 7 days to keep you informed and help decide which therapy will be best for you.
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