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Professional Healthcare Referral

Please complete all the details in the form below.

You should make sure that:

You 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 submit the form.

older man on the phone

"*" indicates required fields

1General Information

2Current Patient Condition

General Information

NHS Number (10 digit number)*

Has the patient consented to this referral?*

Yes

No

Name*

Title* First Name* Last Name*

Date of Birth*

DD slash MM slash YYYY

Preferred Name

If the patient has a preferred name they would like us to use in conversations and correspondence with them, please let us know here. (Their legal name will still have to be used for their NHS medical records)

Gender*

Ethnicity*

Disability

Address*

Main Contact Number*

Secondary Contact Number

Can we leave messages? (Main)

Yes

No

Can we leave messages? (Other)

Yes

No

Can we send text messages?

Yes

No

Postcode*

ZIP / Postal Code

Email (where possible, please supply)*

Does the patient speak English* If not, preferred language

No

Yes

How would you like to be contacted?

Referrer Job Title*

Referrer Name*

Referrer Email*

Organisation you work for*

Possible Risk?*

Yes

No

Any Mental Health Diagnosis?*

Yes

No

Referrer's Comments*

Medication:

Has the patient got a history of substance use?*

Yes

No

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*

Feeling down, depressed or hopeless*

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

Do you have any active plans about harming yourself?*

Feeling nervous, anxious or on edge*

Not being able to stop or control worrying*

Important links
Resources
- Anxiety
- Low Mood
- Depression
- Stress
- Worry
- Mindfulness

Contact Us

Meads Business Centre,
19 Kingsmead,
Farnborough
GU14 7SR

frimleyicb.talkplus@nhs.net

© TalkPlus is an NHS service provided by North Hampshire Urgent Care

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