Self-Referral/Optin – header 07/22

    You may use our web site freely but you can only self-refer if your GP is in Yateley, Fleet, Farnborough, Blackwater, Aldershot, Farnham or Crondall and you are 16 years and older.

    We ask some of the following questions for NHS data gathering purposes (see your information: why we collect data and our duty of confidentiality at the bottom of this page for more information)

    Please complete all the details in the form below and then click the 'Click to continue' button

    You should make sure that:

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

    - all fields marked with an asterisk '*' are required must be completed otherwise you will not be able to click the 'Submit to TalkPlus' button

    Registered GP Surgery? *

    Remember, to self-refer your GP must be in Yateley, Fleet, Farnborough, Blackwater, Aldershot, Farnham or Crondall

    Date of Birth * (we can only accept your referral if you are 16 years or older)

     

    Title *

    Forename *

    Surname *

    Address *

    Postcode *

    Main Contact Number *

    Can we leave messages? YesNo

    Secondary Contact Number

    Can we leave messages? YesNo

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

    Your Email *

    Can we email treatment forms? YesNo

    How would you prefer our Admin team to contact you to arrange your first appointment? *
    (you can discuss your preferred method of treatment during your assessment)

    Gender *

    Ethnicity *

    Religion (if none, enter 'none') *

    Relationship Status *

    Sexual Orientation *

    Smoking *

    Alcohol *

    Drugs *

    Do you have debt problems? *

    YesNo

    Do you have gambling problems? *

    YesNo

    Are you an Asylum seeker *

    Please say where you heard about our service

    ex-Armed Forces *

    YesNo

    Are you, or your partner, pregnant or do you have a child under 12 months old? (tick all that apply) *

    PregnantPartner PregnantChild under 12 months oldnone of these

    Do you have any accessibility requirements we should take into account when allocating appointment premises? *

    NoYes

    Do you have a long-term physical health condition? * If 'Yes' please describe

    NoYes

    Do you have any diagnosed learning disabilities/difficulties, developmental disorders or cognitive impairments that you would like us to be aware of? * If 'Yes' please describe the nature of this disability or difficulty

    NoYes

    Do you require TalkPlus to make any adaptations to enable you to access our service (e.g. an interpreter/large print)? * If 'Yes' please describe the nature of the adaptation you require

    NoYes

    Does your doctor know you are contacting us? *

    YesNo

     

    YOUR CURRENT DIFFICULTIES

    Is the reason you are referring as a result of the recent coronavirus pandemic or related to it? * If yes, please describe.
    NoYes

    Please select your main problem *

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

    At present, what bothers you the most? *

     

    YOUR GOALS

    Bearing in mind that TalkPlus offers short term types of therapy, what would you like to achieve or be able to do differently at the end of your treatment?

    Would you be interested in attending the next available course that teaches people practical coping strategies? *

    YesNo

     

    YOUR PREVIOUS or CURRENT HEALTHCARE

    (e.g. CMHRS, CAMHS, Psychiatrist or other Therapist)

    If you have previously been referred to a Therapist, Psychologist, Counsellor or Psychiatrist, could you please describe who you saw, when it was and what treatment/support you received?

    Are you taking any medication for depression or anxiety? Please give details *

    NoYes

     

    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:

    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 *

     

    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?*

     

    Feeling nervous, anxious or on edge *

     

    Not being able to stop or control worrying *

     

    PLEASE NOTE:

    We may use and share 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