Referral Form - Self Help

Your service

Which service you would like to access?

Referrers’ details

First Name*

Last Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Landline number

Mobile number

Email address

I confirm I have the permission of the person I am referring*

Yes

I confirm the person I am referring gives permission for you to discuss details of their referral with me?

Yes

Details of the person you are referring

First Name*

Last Name*

Address*

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Date of Birth*

Gender*

Male
Female
Prefer not to say

NHS Number

We really need this, if possible. NHS numbers can be found on:
• A medical card
• A letter from a GP or a hospital

Landline number

Mobile number

Email Address

Getting in touch with the person

Getting in touch with you

Please tick A, B or C if you give permission for us to:

A) Leave a message with someone answering my phone
B) Leave a message on my answering machine
C) Send reminders via text message to your mobile
D) Send a message via email

GP's details for the person being referred

GP Practice

We are required to notify your GP that you are accessing our service. Please provide permission for us to write to your GP with this information. Unfortunately if your GP is not listed in the drop down we are unable to offer you support via our service. Please search NHS choices for your local IAPT provider.

Does the person give Self Help permission to contact their GP?*

We are required to notify your GP that you are accessing our service. Please provide permission for us to write to your GP with this information. Please note that if you do not give permission we are unable to offer you this service.

Yes, I give you permission to contact my GP
No, I don't give you permission to contact my GP

Presenting Problem

Please provide a brief summary of the client's problem*

Are they exprincing any issues related to the below. Please tick where appropriate.

Domestic abuse
Housing
Isolation
Work-related

Additional information

What is their marital status?

White

British
Irish
Any other white background

Mixed

White and Black Caribbean
White and Black African
White and Asian
Any other mixed background

Asian or Asian British

Indian
Pakistani
Bangladeshi
Any other Asian background

Black or Black British

Caribbean
African
Any other black background

Chinese or other ethnic group

Chinese
Any other

What is their religion?

Is English their first language?*

Yes
No

If no, please give details

Do they have any problems speaking, reading or writing English?*

Yes
No

If yes, please give details

Do they have any disabilities we should be aware of?*

Yes
No

If yes, please give details

Have they served in the Armed Forces?*

Yes
No

If yes, please give details

Do they have any long term health conditions?*

Yes
No

If yes, please give details; e.g. visual, speech, hearing, mobility.

If yes, please give details

Is the client or their partner currently pregnant; or had a baby in the last 2 years?*

Yes
No

If yes, please give details

Where did you hear about the service?