Referral Form

You will be eligible for this service if you are aged over 18 and live in, or are registered with a GP located in the Kingston borough - if you do not fit this criteria, you can find your local service at www.nhs.uk/service-search/mental-health/find-an-NHS-talking-therapies-service

This self-referral form is a way for you to access psychological support and advice from your local NHS Talking Therapies service. The service is for people who are experiencing stress, worry or low mood, or are struggling to cope with everyday life due to emotional difficulties.

If you have a history of serious mental health difficulties or drug and alcohol problems, we suggest you speak to your GP before filling out this form as they may recommend other services more able to help you.

If you require urgent help please contact your GP, call the Mental Health Crisis Line which is open 24/7 on 0800 028 8000, or if someone’s life is at risk, please attend your local Accident and Emergency Department or call 999.

We do not offer assessments for ADHD or ASD – please contact your GP to discuss a referral if you wish to access an assessment for ADHD or ASD.

By completing and submitting this form, you are consenting to have this information stored confidentially on our secure electronic record system separate from your GP's system, and for your GP to be informed of your contact with us.

If you have difficulties completing this form, or if you would prefer to complete this form on paper, please call 0203 513 4440 and one of our administrators will be pleased to help you.

By providing these details you are giving consent for us to contact you.

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:*

Please provide the name of the GP surgery you are registered with:*

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:

Do you care for someone with a disability or long term illness (including a severe mental illness or addiction) who could not cope without your support?*

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