Referral information
Please let us know if this is a:
* Required
If you selected 'referral from a healthcare professional', please complete the below details:
Referrer name
Referrer contact telephone number
* Required
Referrer email address
Your details
Title
* Required** None Dr Miss Mr Mrs Ms Mx Prof Rev
First name
* Required
Last name
* Required
Date of birth
* Required
Date
Gender
* Required** None Female Male Non-binary Not known Not specified Transgender female Transgender male
Address line 1
* Required
Address line 2
Town/City
* Required
Postcode
* Required
Please note: We use your email address to confirm appointments only.
Email address (If you don't have an email address, please add - noemail@nhs.net)
Can we leave a voicemail on your mobile number
Contact telephone number
* Required
Can we send text messages to your mobile number?
Other contact number (For example, work or home telephone)
Can we leave a voicemail on your other number?
GP details
GP name
GP surgery name
* Required
Can we contact the GP?
* Required
Your GP holds a duty of care for you. We find it helpful for people when we keep their GP up to date about whether they are accessing our service so that they can coordinate your care appropriately.
Please be aware that at times we may need to contact your GP without your consent, in the interests of promoting safety. If we are concerned about your, or others' safety, we will need to let your GP know about this as they hold a duty of care for your wellbeing.
Referral information
Why do you want to refer to the service?
* Required** None Anxiety linked to excessive worry (Generalised Anxiety Disorder) Anxiety linked to having panic attacks Anxiety linked to social situations (Social Phobia) Anxiety linked to specific phobia (please detail below) Anxiety linked to specific situations like crowded spaces (Agoraphobia) Anxiety linked to worry about my health (Health Anxiety) Bereavement Body Dysmorphic Disorder (BDD) Low mood/depression Mixed depression and anxiety Obsessive Compulsive Disorder (OCD) Post-Traumatic Stress Disorder (PTSD)
If 'other' please provide a brief description of your problem:
Are you being seen by another service for mental health problems?
* Required
If you answered 'yes', please give details
Where did you hear about us?
Further information
What is your nationality?
* Required** None British English Irish Other Scottish Welsh
What is your preferred language?
* Required** None Akan (Ashanti) Albanian Amharic Arabic Bengali & Sylheti Brawa & Somali British Signing Language (BSL) Cantonese Cantonese & Vietnamese Creole Dutch English Ethiopian Farsi (Persian) Finnish Flemish French French creole Gaelic German Greek Gujarati Hakka Hausa Hebrew Hindi Igbo (Ibo) Italian Japanese Korean Kurdish Lingala Luganda Makaton (sign language) Malayalam Mandarin Norwegian Other Pashto (Pushtoo) Patois Polish Portugese Punjabi Russian Serbian/Croatian Sinhala Somali Spanish Swahili Swedish Sylheti Tagalog (Filipino) Tamil Thai Tigrinya Turkish Urdu Vietnamese Welsh Yoruba
Do you speak English?
* Required
Are you able to understand written English?
* Required
Do you need a translator?
* Required
If yes, what language do you need?
Do you need any additional support in accessing our service?
If other, please let us know here
Are you a carer for someone?
* Required
Do you have a carer?
* Required
If yes, would you like your carer to be involved in your treatment?
If yes, please provide the details of your carer below
Name
Relationship to you (patient)
Contact telephone number
Address
Are we able to speak to your carer about this referral (if we are unable to contact you)?
What is your ethnicity?
* Required** None Asian or Asian British - Any other Asian background Asian or Asian British - Bangladeshi Asian or Asian British - Indian Asian or Asian British - Pakistani Black or Black British - African Black or Black British - Any other Black background Black or Black British - Caribbean Mixed - Any other mixed background Mixed - White and Asian Mixed - White and Black African Mixed - White and Black Caribbean Not known Not stated Other Ethnic Groups - Any other Ethnic Group Other Ethnic Groups - Arab Other Ethnic Groups - Chinese Other Ethnic Groups - Columbian Other Ethnic Groups - Ecuadorian Other Ethnic Groups - Filipino Other Ethnic Groups - Iranian Other Ethnic Groups - Iraqi Other Ethnic Groups - Japanese Other Ethnic Groups - Middle Eastern Other Ethnic Groups - Other Latin American Other Ethnic Groups - Vietnamese White - Any other White background White - British White - Irish
What is your religion?
* Required** None Agnostic Any other religion Baha'i Buddhist Christian Do not wish to state Hindu Jain Jewish Muslim No religious group or secular Pagan Parsi/Zoroastrian Sikh Unknown
What is your sexual orientation?
* Required** None Bisexual Do not wish to state Heterosexual Lesbian or gay Not known Other
Do you have a disability or long-term condition?
* Required** None Yes No
If yes, what is it?
** None Arthritis Asthma Cancer Chronic fatigue (tiredness) Chronic kidney disease Chronic Obstructive Pulmonary Disease (COPD) Chronic pain (including Fibromyalgia) Chronic pancreatis Coronary heart disease Crohn's disease Dementia Diabetes Don't know/not sure Eating disorder Epilepsy Hypertension/high blood pressure Irritable Bowel Syndrome (IBS) Medically unexplained symptoms Musculoskeletal disorder (MSK) None Osteoporosis Other Parkinson's disease Prefer not to say Severe mental health problems Stroke and transient ischaemic attacks Thyroid problems
If other, please specify
Do you have any of the following medically unexplained symptoms?
* Required
Are you an ex-member of the British Armed Forces?
* Required
To make our service accessible to your needs, please let us know if you
What will happen next
If we think we may be able to help you we'll offer you an assessment appointment with one of our team.
If we think that you could benefit from a different service we'll contact you to let you know.
If we decide that we're not the right service to offer you therapy, we may send your referral to another service that may be more appropriate for you within our Trust.
If you have questions about how we manage your information, you are welcome to discuss these with any staff member involved in your care.
