Professional Referral

    Professional Referral

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

    You should make sure that:

    - you please double check all telephone numbers so we are able to contact the patient;

    - referral must include PHQ9 and GAD7 scores to help our screeners and therapists;

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

     

    Has the patient consented to this referral? (required) Y N

     

    NHS Number (10 digit number) (required)

    Title (required)

    Forename (required)

    Middle names

    Surname (required)

    Date of Birth (required)

    Gender (required)

    Disability (required)

    Does the patient have any physical long term conditions? YN
     

    Address (required)

    Postcode (required)

    Mobile Number (required)

    Can we leave a message? (required) YN

    Can we send a text? (required) YN

    Landline Number

    Can we leave a message? YN

    Email (where possible, please supply)

    Consent to contact by email? (required if email given) YN

     

    English spoken? (required) YN if not, preferred language

    Referrer Name (required)

    Referrer Job Title (required)

    Referrer Service (required)

    Referrer Telephone (required)

    Referrers comments (required)

    Possible Risk? (required) NY
    n.b. If there is any significant immediate risk, please make an urgent referral to the CMHRS
    if Yes, please describe risk

    Medication:

    Any mental health diagnosis? NoYes (please describe)  

    If the patient has received previous psychological support, please give details:

    Has the patient got a history of substance use? NoYes

    What support are you currently providing/planning to provide and are you planning to still see them alongside us or discharge?

    Current Patient Condition

    Please indicate how often patient has been bothered by the following problems over the last two weeks:

    Little interest or pleasure in doing things (required)

     

    Feeling down, depressed or hopeless (required)

     

    Thoughts that they would be better off dead or of hurting themself in some way (required)

     

    Do they have any active plans about harming themself? (required)

     

    Feeling nervous, anxious or on edge (required)

     

    Not being able to stop or control worrying (required)