Recite - Accessibility and Language Options

Part One: Self Referral Form

Part One: Referral Form › Review & Submit ›

Your consent

I am aged 16 or over.

I am currently, or have been in the last 12 months, under the care of a secondary mental health service (such as a Community Mental Health Team or Acute Mental Health Team).

I am currently receiving talking therapy from another service (such as counselling).

I have read and understood the privacy notice.

Your details

Please note that mandatory fields are marked with an asterisk (*).

As an NHS Service we need to record your 10 Digit NHS Number. Please check for your NHS Number on the NHS website: www.nhs.uk/nhs-services/online-services/find-nhs-number/

Your 10 Digit NHS Number

*Title

*DOB

*Gender

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

Pronouns

Other

*First Name

*Surname

*Address line 1

Address line 2

Town/City

County

*Postcode

*Home telephone number

Can we leave a voicemail?

*Mobile telephone number

Can we leave a voicemail?

Can we text you appointment reminders, links to book an appointment and links to access letters relating to your care?

If you do not have a Home or Mobile number, please enter 'N/A' in the relevant field. Please note that we need at least one form of contact to carry out Telephone Assessments.

Do we have permission to leave a message with someone else if you are unavailable?

If Yes, provide their name in free text box.

Do we have consent to take a message from someone else on your behalf?

If Yes, provide their name in free text box.

When would you be available to take a call from NHS Talking Therapies Hampshire? Please indicate any preferred days/times in the box below.

We will do our best to contact you on your preferred day/time however this cannot be guaranteed. Our phone line is open 9am–6pm (Monday to Thursday) and 9am–4:30pm (Friday). Staff are available 8am–8pm (Monday to Thursday) and 8am–4:30pm (Friday).

*Email Address

*Permission to contact by Email?

(Please note: If you do not provide consent you will not be sent a confirmation email or booking reminders for any contact with NHS Talking Therapies Hampshire)

How would you prefer we contact you? you may select more than one option

Phone
email
Letter
SMS

Next of kin details

Please provide us with your next of kin details. This provides the team involved in your care with useful and up-to-date information should there be an emergency. You can decline to give us next of kin details if you wish and this will not affect your treatment with us.

Next of Kin Name

Relationship to you

Telephone number

*Please let us know how much information we can share should we need to contact your next of kin

OR Do you wish to decline to provide information of next of kin?

Sometimes we may need to share relevant information about you with family or other healthcare staff in order to look after your wellbeing. We will never share your information with anyone unrelated to your care and we protect your privacy and handle your personal information in line with the General Data Protection Regulation (GDPR) guidance. Examples where we may need to share information about you are: -If you are unable to communicate your wishes and action is needed for your health and safety or that of another person. -Where there is concern for your life or that of another person. -Legal reasons that require the sharing of information. Please let us know who we can share information on your care with below:

I would like you to share with:

I would NOT like you to share with:

Please share any other information sharing preferences:

Your Personal Information

Nationality

Are you a Refugee or Asylum Seeker?

Ethnicity

Religious Belief or Affiliation

Language

Are you able to communicate in English?

Relationship Status

Sexuality

Disability

Are you currently in education?

Do you have any additional needs that you need support with (e.g. an interpreter, large print documents etc)?

If Yes, provide details in free text box Characters Remaining: 500

Do you have a learning disability?

If Yes, provide details in free text box. Characters Remaining: 500

Are you currently under the care of or receiving support by any other Healthcare service, Team or Professional?

If yes please provide details in the free text box Characters Remaining: 500

NHS Talking Therapies Hampshire Health

NHS Talking Therapies Hampshire Health is our treatment pathway for people with a long-term physical health condition. Our NHS Talking Therapies Hampshire Health treatment options explore the mind-body link, and aim to equip you with tools to build your resilience and live well with a long-term physical health condition.

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

Is the impact of your long-term condition on your mental health part of your reason for referring?

It can be helpful for us to work together with your physical health teams. Are you happy for us to keep them updated about your care?

If yes, please provide contact details for your physical health team(s) Characters Remaining: 500

Armed forces

Are you an ex-serving member of the British Armed Forces?

Service Number

Length of Service (Years)

Length of Service (Months)

Discharge Date

Rank at Discharge

Mode of Discharge

Details of any operational tours Characters Remaining: 500

Are you a spouse/romantic partner/child/ex-partner of serving personnel?

Are you a spouse/romantic partner/child of an ex serving member of the armed forces?

Your GP surgery details

NHS Talking Therapies Hampshire is the local talking therapy service for Hampshire. If your GP surgery is not listed below, we are not able to accept your referral. Instead, search "IAPT" at www.NHS.uk to find your local talking therapy service.

*GP Surgery

GP Name

GP Address

If you do not know the name of your GP, please put 'Unknown' under 'GP Name'.

*Do you consent for your GP to be notified of your self-referral to NHS Talking Therapies Hampshire?

We can still offer you an appointment without your consent to share with your GP. However your practitioner will discuss our policy about GP consent with you. If you have any questions about this please call us on 02380 383920.

Perinatal

Are you pregnant?

Are you a parent to a child under 1 year old?

*How did you hear about NHS Talking Therapies Hampshire?

About your mental health

*Have you ever had a mental health diagnosis? For example, bi-polar, personality disorder, schizophrenia

*From the following list, which best describes the reason for your referral?

If 'other', please describe the reasons for your referral (e.g. post-traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), social anxiety, social phobia, health anxiety) Characters Remaining: 500

At NHS Talking Therapies Hampshire we specialise in supporting people with symptoms of anxiety, depression, PTSD, OCD and phobias as their main problem. However, if you’ve been diagnosed with another mental health condition, or your main problem is something different such as addiction or disordered eating, we may link you with another trusted service.

Cancel

Recite - Accessibility and Language Options