Self-Referral/Optin

SELF-REFERRAL AND OPT-IN

Please complete all the details in the form below and then click the 'Send to TalkPlus' button.

You should make sure that:

- you double check any telephone numbers you give us as we will use them to contact you;

- you indicate which day and time would be most appropriate to call you;

- all fields must be completed otherwise you will not be able to click the 'Submit to TalkPlus' button.


 

Title (required)

Forename (required)

Surname (required)

Date of Birth (required)

Address (required)

Postcode (required)

Main Contact Number (required)

Can we leave messages? YesNo

Secondary Contact Number

Can we leave messages? YesNo

Can we text message you (for appointments etc.) YesNo

Your Email (required)

Can we email treatment forms? YesNo

Gender (required)

Ethnicity (required)

Religion (if none, enter 'none')

Relationship Status (required)

Sexual Orientation (required)

Please say where you heard about our service

ex-Armed Forces (required)
YesNo

If ex-Armed Forces is your problem related to your service
YesNo

Are you, or your partner, pregnant or do you have a baby under 12 months old? (required)
YesNo

Do you have a disability we should take into account when allocating appointment premises? (required)
YesNo

Do you have a long-term physical health condition? (required) If 'Yes' please describe
NoYes

Does your doctor know you are contacting us? (required)
YesNo

Registered GP Surgery? (required)

Registered GP name? (required)

 

YOUR CURRENT DIFFICULTIES

Please select your main problem (required)

Please give any further details that you feel would help us understand your current problem?

 

YOUR PREVIOUS or CURRENT HEALTHCARE
(e.g. CMHRS, Psychiatrist or other Therapist)

Name of Previous Therapist?

Type of Therapist? (e.g. Counsellor, Psychiatrist)

Name of Service?

When did you access this service?

Are you taking any medication for depression or anxiety? Please give details (required)
NoYes

If so, are you taking it regularly?
YesNo

Preferred day for us to call you (required)

Preferred time slot for us to call you (required)

 


Your answers to the following questions will help us assess your current condition. Your referral cannot be submitted until this section is fully completed.

Please indicate how often you have been bothered by the following problems over the last two weeks:

PHQ9

Little interest or pleasure in doing things

 
Feeling down, depressed or hopeless

 
Trouble falling or staying asleep, or sleeping too much

 
Feeling tired or having little energy

 
Poor appetite or overeating

 
Feeling bad about yourself, or that you are a failure, or have let yourself or your family down

 
Trouble concentrating on things such as reading a newspaper or watching television

 
Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual

 
Thoughts that you would be better off dead or of hurting yourself in some way

 
If you have chosen 1,2 or 3 on the last question, please answer the following question:
Do you have any active plans about harming yourself?

 


GAD7

Feeling nervous, anxious or on edge

 
Not being able to stop or control worrying

 
Worrying too much about different things

 
Trouble relaxing

 
Being so restless that it is hard to sit still

 
Becoming easily annoyed or irritable

 
Feeling afraid as if something awful might happen

 


PHB

On a scale of 0-8, please select a number to indicate how much you would avoid the following:

Social situations, due to a fear of being embarrassed

 
Avoid situations for fear of a panic attack/distressing symptoms (vomiting/dizziness)

 
Avoid objects/activities (animals/heights/seeing blood/driving)

 


WSAS

On a scale of 0-8, please select a number to indicate how much your problems impact on the following areas of your life:

Work (If you are retired or choose not to work, please enter 0)

 
Home Management

 
Social leisure activities

 
Private leisure activities/Hobbies

 
Family and relationships

 


EMP/BEN

Please select the option that best describes your current employment status
 

Are you currently receiving any of the following:


PLEASE NOTE:
We may request/provide information to/from your GP and other NHS organisations to assist with your assessment and treatment and will send a summary of your treatment to your GP. We may use and share your NHS Number and non-identifiable data about your treatment to provide statistics on the performance and effectiveness of our service with NHS England, NHS Digital and the local NHS Clinical Commissioning Group relevant to your area.
Please check here to acknowledge your consent Yes