SELF-REFERRAL AND OPT-IN - REVISED July 21
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 '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;
- all fields marked 'required' must be completed otherwise you will not be able to click the 'Submit to TalkPlus' button
Registered GP Surgery? (required)
---Alexander HouseThe Border PracticeBranksomewood Healthcare CentreThe Cambridge PracticeCrondall New SurgeryDowning Street Group PracticeFarnham Dene Medical PracticeThe Ferns Medical PracticeFleet Medical CentreGiffard Drive SurgeryHolly Tree PracticeJenner House SurgeryMayfield Medical CentreNorth Camp SurgeryOakley Health GroupPrinces Gardens SurgeryRichmond SurgeryRiver Wey Medical PracticeThe Wellington PracticeVoyager Family HealthI'm not registered Remember, to self-refer your GP must be in Yateley, Fleet, Farnborough, Blackwater, Aldershot, Farnham or Crondall
Date of Birth (required) (we can only accept your referral if you are 16 years or older)
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
How would you prefer our Admin team to contact you to arrange your first appointment? ---TelephoneText/SMSEmail
(you can discuss your preferred method of treatment during your assessment)
---MaleFemaleTrans MaleTrans FemaleOtherDon't know
---White BritishWhite IrishWhite OtherMixed White and Black CaribbeanMixed White and Black AfricanMixed White and AsianMixed OtherAsian IndianAsian PakistaniAsian BangladeshiAsian OtherBlack CaribbeanBlack AfricanBlack OtherChineseNepalese
Religion (if none, enter 'none')
Relationship Status (required)
---SingleMarriedDivorcedWidowedSeparatedCohabitingLong Term (not cohabiting)Civil Partnership
Sexual Orientation (required)
---HeterosexualLesbian or GayBisexualOtherDon't know
---SmokerEx-smokerNever smoked tobacco
---No alcohol problemI use alcoholI am alcohol dependent
---Not a drug userI use drugsI am dependent on drugs
Do you have debt problems?
Do you have gambling problems?
Are you an Asylum seeker (required)
---Not an Asylum-seekerAsylum seekerAsylum seeker awaiting decision on refugee statusAsylum seeker with application for asylum refusedAsylum seeker with discretionary leave to remainAsylum seeker with humanitarian protection statusUnaccompanied child asylum seeker
Please say where you heard about our service
---GP recommendationOther ClinicianPoster/AdvertGoogle searchFriend or relativeYour EmployerWord of MouthStaff Resilience HubGP web siteOther
ex-Armed Forces (required)
Are you, or your partner, pregnant or do you have a child under 12 months old? (tick all that apply) (required)
PregnantPartner PregnantChild under 12 months oldnone of these
Do you have any accessibility requirements we should take into account when allocating appointment premises? (required)
Do you have a long-term physical health condition? (required) If 'Yes' please describe
Do you have any diagnosed learning disabilities/difficulties, developmental disorders or cognitive impairments that you would like us to be aware of? (required) If 'Yes' please describe the nature of this disability or difficulty
Do you require TalkPlus to make any adaptations to enable you to access our service (e.g. an interpreter/large print)? (required) If 'Yes' please describe the nature of the adaptation you require
Does your doctor know you are contacting us? (required)
YOUR CURRENT DIFFICULTIES
Is the reason you are referring as a result of the recent coronavirus pandemic or related to it? (required) If yes, please describe. NoYes
Please select your main problem (required)
---Worry or AnxietyLow Mood or DepressionPhobia or Specific FearPanic AttacksDifficult SleepingManaging my physical health conditionAny Other Problem
Please give any further details that you feel would help us understand your current problem?
At present, what bothers you the most?
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? (required)
YOUR PREVIOUS or CURRENT HEALTHCARE
(e.g. CMHRS, CAMHS, 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)
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 ---0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day
Feeling down, depressed or hopeless ---0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day
Thoughts that you would be better off dead or of hurting yourself in some way ---0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day
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? ---0 - No, I feel I am currently not a risk to myself1 - Yes, but I have things in place that keep me safe (e.g. family, friends, pets) and feel I am currently not a risk to myself2 - Yes and I feel I am at risk of seriously harming myself in some way
Feeling nervous, anxious or on edge ---0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day
Not being able to stop or control worrying ---0 - Not at all1 - Several days2 - More than half the days3 - Nearly every day
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