Referral Form

Welcome

Thank you for choosing NHS Talking Therapies Hampshire. We provide free confidential support for people aged sixteen or over and registered with a GP in Hampshire. This excludes Northeast Hampshire, Isle of Wight, Portsmouth City, and Southampton City. If you are under sixteen, please speak to your GP for local support. If you are a healthcare professional, please use the professional referral form.

We can only offer one form of treatment at a time. Please do not complete this form if you have already completed a referral for a course or Silvercloud.

All questions marked with * are required. If you need help completing this form, call us on 023 8038 3920.

https://hiowhealthcare.nhs.uk/privacy-notice

Yes

I have read and understood the privacy notice*

Are you currently receiving therapy or support from any mental health team? Not including private counselling or any local Mind services*

Yes

No

If you have answered yes to receiving therapy from another team or mental health service, we are unable to accept a referral from you currently. For more information, please contact us on 023 8038 3920.

Have you been under any other mental health service or team in the last 12 months?*

Yes

No

If yes which service was this?

Title*

First Name*

Surname*

Preferred name

Date of Birth*

Gender*

Is the gender you identify with the same as you were assigned at birth?

Yes

No

Pronouns

Address Line 1*

Address Line 2

Town/City

County

Postcode*

Home telephone number

Can we leave a voicemail?

Yes

No

Mobile telephone number

Can we leave a voicemail?

Yes

No

Can we send you reminders by text about appointments, links to book your appointment and to access letters relating to your care?

Yes

No

Email Address

Please re-enter Email Address

Permission to contact by email?

Yes

No

Can we send you secure questionnaires by email before each appointment?

Yes

No

Preferred contact method

Phone

Email

SMS

Letter

Do we have your consent to take a message about your appointment from someone on your behalf?*

Yes

No

Name of nominated person

If we are unable to contact you with any updates to your appointment, do you consent to us leaving a message with someone on your behalf?*

Yes

No

Name of nominated person

Contact number

How can we contact them?

Text

Call

If yes to a phone call, can we leave a voicemail message?

Yes

No

If you are registered with Living Well Partnership Bitterne Park, Harefield, Thornhill Park, Midanbury and Weston Lane please contact Talking Therapies Southampton.

GP Surgery name*

GP Address*

GP Name (if known)

Do you give us consent for your GP to be notified of your referral and to be updated about your support with us?*

Yes

No

Do you give us consent for other healthcare professionals to be contacted for information relevant to your care or to support you further?*

Yes

No

This could include healthcare professionals currently supporting you, or teams we may recommend referring you to in future.

Do you have a long-term physical health condition?*

Yes

No

If yes, please select

If other, please specify

Is this affecting your mental health and the reason for your referral?

Yes

No

Nationality

Ethnicity

Are you a refugee or asylum seeker?

Yes

No

First language

Do you need an interpreter?

Yes

No

Disability

Religion

Sexuality

Are you pregnant?

Yes

No

Are you a parent of a child under 12 months?

Yes

No

Are you an ex-serving member of the armed forces?

Are you dependent on an ex-serving member?

Yes

No

Are you a spouse, romantic partner, ex partner or child of serving member?

Yes

No

Are you a student?

Yes

No

If 'Yes', at which type of institute?

Do you have any additional need to be able to access our service? (e.g., large print, interpreter, hearing support)

Yes

No

Do you have a learning disability?

Yes

No

If yes, are you happy to provide us with more information?

Are you currently under the care of any other health teams or professionals?*

Yes

No

Details

Have you ever had a mental health diagnosis? e.g. bipolar, personality disorder, schizophrenia*

Yes

No

What best describes the reason for your referral?*

If other, please describe briefly

Have you got any employment difficulties?*

Yes

No

We will always aim to ask your consent before sharing any of your information. Occasionally, we may share your information without your prior knowledge if we are concerned about your safety or someone else's. Sometimes we may need to share relevant information with family or healthcare professionals to look after your wellbeing. We will never share your information with anyone unrelated to your care.

Who can we share information with?

Is there anyone you do NOT want us to share information with?

Next of kin details (optional):

Name

Relationship

Phone

How much information can we share?

Would you be happy to give feedback later?

Yes

No

How did you hear about us?*

We are committed to ensuring the shortest waiting times for our patients and the best possible outcomes. It may therefore be necessary to send your information to a third party to complete your treatment. This third party adheres to the NHS data processing standards. For further information on how we manage your personal information, please see: https://hiowhealthcare.nhs.uk/privacy-notice

Our phone lines are open:

Mon–Thu: 8am–6pm, Fri: 9am–4:30pm

Please complete the captcha

Self-referral form

Welcome

Before you start

Section 1: About you

Section 2: Your GP

Section 3: Your health

Section 4: Additional information

Section 5: Your mental health

Section 6: Employment difficulties

Section 7: Consent and preferences

Helpful information