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)
—Please choose an option—JanuaryFebruaryMarchAprilMayJuneJulyAugustSeptemberOctoberNovemberDecember
Gender (required) —Please choose an option—MaleFemaleTransgenderNot knownIndeterminateOther
Disability (required) —Please choose an option—VisualSpeechHearingMobilityNoneOther
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) —Please choose an option—0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day
Feeling down, depressed or hopeless (required) —Please choose an option—0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day
Thoughts that they would be better off dead or of hurting themself in some way (required) —Please choose an option—0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day
Do they have any active plans about harming themself? (required) —Please choose an option—0 - No, they feel they are currently not a risk to themself1 - Yes, but they have things in place that keep them safe (e.g. family, friends, pets) and feel they are currently not a risk to themself2 - Yes and they feel they are at risk of seriously harming themself in some way
Feeling nervous, anxious or on edge (required) —Please choose an option—0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day
Not being able to stop or control worrying (required) —Please choose an option—0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day
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