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

We do not provide urgent or immediate support. If urgent or immediate support is required, please contact the client’s GP / the Kingston Crisis Line on 0800 028 8000 / urge client to visit their local Accident & Emergency department. They can also contact The Samaritans on 116123.

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

Please complete all parts of the form – missing information will delay referrals.

Your name:*

Organisation:*

Job title:*

Email:*

Telephone:*

Does the client understand the remit of the service and have they agreed to a referral?:*

Yes

Title:*

Surname:*

First Name:*

Date of Birth:*

NHS Number:

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 text messages:

Yes

No

Email:

Permission to send emails:

Yes

No

Name:*

Phone number:*

Email:*

Please note, we can only accept referrals for patients residing in Kingston borough, registered with a GP in Kingston Borough, or NHS / social care staff working within Kingston Borough.

GP Surgery:*

Relationship status:

Gender:*

If client preferred to self-describe, please describe here:

Is this the client’s birth gender?

Yes

No

Prefer not to say

Pronouns:

Sexuality:*

If other, please describe:

Nationality:

If other, please describe:

Ethnicity:*

Religious group:

Primary language:

Interpreter needed?:*

Yes

No

If client does not speak English, is there a named contact for helping to book appointments:

Is the client receiving care from other services:

Yes

No

If yes, please give details:

Does the client need support to access services (e.g. hearing or sight issues, physical disabilities, difficulties with reading and/or writing or learning difficulties):

Yes

No

If yes, please describe:

Does the client have a long term physical health condition:*

If other, please describe:

Is the client pregnant:*

Yes

No

If yes, estimated due date:

Children under 1:*

Yes

No

Please provide details of services involved e.g. midwife/health visitor, bridge team, perinatal mental health team, social services:

Does the client care for someone with a disability or long term illness (including a severe mental illness or addiction) who could not cope without their support?*

Current / Ex-British Armed Forces:*

Reason for referral: Include current/historical diagnoses, treatment including prescribed medication, safeguarding issues if known:*

Please indicate if you have a view about which intervention might be helpful (see our website for more details):

Current Risk/Safeguarding: Please note that we rely on information about risk / safeguarding to ascertain whether our service is safe for the client. If risk information is not complete it will be assumed that there are no risk or safeguarding issues.

Risk:

Provide details:

If there are safeguarding issues, have you made a safeguarding referral?:

Yes

No

Current / history of forensic issues: are they a risk to specific persons or staff?

Substance misuse / addiction issues:

Other relevant information / previous history:

Current social situation (housing, employment, finances):

Please add any additional helpful information (e.g. information from GP history, assessments, reports):

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

If we feel that another NHS service is better placed to support the client we will pass on the client’s details.

Please select this option if the client does not want us to share their information in such circumstances:*

Yes - Client is happy to be referred on

No – Client does not wish to be referred on

Please complete the captcha

Professional Referral Form

Referrer details

Client details

Next Of Kin/Emergency Contact Details

GP details

Further client details

Referral reason