You may notice a temporary change in the referral form's appearance. This is a result of our ongoing technical upgrades.

Please note that in order to access our service you will need to either be a resident or be registered with a GP, in the London Borough of Hounslow. If you're unsure which IAPT service covers your area, please click here to find your NHS talking therapies local service,  or arrange to speak to your GP.

In response to the COVID-19 pandemic, if you work for the NHS or in a care setting in North West London you will be eligible for priority access to support, to access this, please complete the below referral form. For further information visit: http://www.keepingwellnwl.nhs.uk

*Hammersmith & Fulham, Hounslow, Ealing, Harrow, Brent, Kensington & Chelsea, Westminster, Hillingdon.

Back on Track is not an emergency service and this referral form should not be used if you require urgent support. If you are worried about the immediate risk of harm to yourself or others, please speak to your GP. Alternatively, you can also contact the following services 24 hours a day, 7 days a week: West London Health Trust Helpline (0800 328 4444) NHS Helpline (111), and the Samaritans (116 123).

In taking your details, we recognise the importance of personal privacy and make sure all information about you is held securely in accordance with the General Data Protection Regulation (GDPR)

We use data anonymously for monitoring purposes. However, no one will be able to link any information back to you.

Everything you tell us is kept confidential, however, if you disclose information concerning current or potential harm or risk to yourself or another, we may need to tell another party including your GP, the Police or Ambulance Service.

Required

Referral information

Please let us know if this is a: Required

If you selected 'referral from a healthcare professional', please complete the below details:

Required

Your details

Required
Required
Required
Date of birth Required
Required
Required
Required
Required

Please note: We use your email address to confirm appointments only.

Can we leave a voicemail on your mobile number
Required
Can we send text messages to your mobile number?
Can we leave a voicemail on your other number?

GP details

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


 

Required
Are you being seen by another service for mental health problems? Required

Further information

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Do you speak English? Required
Are you able to understand written English? Required
Do you need a translator? Required
Do you need any additional support in accessing our service?
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

Address
Are we able to speak to your carer about this referral (if we are unable to contact you)?
Required
Required
Required
Required
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.

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