Referral Form

Kingston Talking Therapies offers short term psychological therapies for adults (18+) with anxiety and depression who are ready and able to work on their difficulties. For information on Talking Therapies, visit our website: swlstg.nhs.uk/kingston-talking-therapies

If you are unsure if our service is appropriate, or if you have any problems completing this online form, please contact us at kingstontalkingtherapies@swlstg.nhs.uk or 0203 513 4440

Please provide as much information as you can. This will help us to decide if our service will be suitable for you.

Before you begin, where did you hear about us?:

If other, please describe:

Title:*

Surname:*

First Name:*

Date of Birth:*

NHS Number (if known):

Address Line 1:*

Address Line 2:

City:*

Postcode:*

Permission to send letters:

Yes

No

Landline:

Permission to leave voicemail messages:

Yes

No

Mobile:*

Permission to leave voicemail messages:*

Yes

No

Permission to send texts:*

Yes

No

Email:

Permission to send emails:

Yes

No

Name:*

Phone number:*

Email:*

We ask for your GP details so we can share basic information and contact them about your care if needed. Where possible we will discuss this with you first. We can only see people with a GP in Kingston.

GP Surgery:*

Consent to liaise with GP:

Yes

No

We ask the following questions to help us ensure that our service is inclusive for everyone.

Are you in a relationship:

Gender:*

Please self-describe here:

Is this your birth gender?:

Yes

No

Prefer not to say

Which pronouns do you use?:

Sexuality:*

If other, please describe:

How would you describe your nationality?:

If other, please describe:

What is your ethnic group?:*

Religion:

If any other religion, please describe:

Preferred Language:

Do you need an interpreter?:*

Yes

No

If you do not speak English, please give us details of someone you trust who we can contact to book appointments.

Name of someone you trust:

Their phone number:

Do you need support to access services (e.g. do you have hearing or sight issues, physical disabilities, difficulties with reading and/or writing):

Yes

No

If yes, please describe:

Do you have a physical health condition?:

If other, please describe:

Are you pregnant?:

Yes

No

If yes, what is your estimated due date?:

Do you have children under 1?:

Yes

No

Please provide details of any pregnancy or early years services involved e.g. a midwife/health visitor, bridge team, perinatal mental health team, social services:

Are you currently or have you ever been a member of the British Armed Forces:

Are you receiving care from any other mental health or physical health services?:

Yes

No

If yes, please give details:

Have you received in the past, or are you currently receiving counselling, therapy or other mental health support elsewhere?:*

Yes

No

Unsure

If yes, please provide further details:

Please provide brief details of your problem or what you would like us to help you with:*

Would you be willing to have online treatment with our service? (this may include online therapy programmes, communication with your therapist online and/or video sessions):

Yes

No

Not sure

If we feel that another NHS service is more suitable for you, we would like to send your referral to this service, and also notify your GP:

Yes my referral can be sent to another more suitable NHS service

No I do not want my details shared with other NHS services

Please send any additional helpful information such as discharge summaries, reports etc to kingstontalkingtherapies@swlstg.nhs.uk

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Self Referral Form

Your details

Next Of Kin/Emergency Contact Details

GP details

More details about you