Refer into NHS Talking Therapies as a professional
About the referrer
Your name
Required
Your organisation
Required
Your contact number
Required
Your email address
Required
About the service user
Full name
Required
If the service user has been known by any other names, please state them here.
First line of service user's address
Required
Postcode
Required
Mobile telephone number
Required
Home telephone number
The service user will be sent a verification email to confirm the referral has been sent and received if you provide us with an email address. We strive to be 100% paper-free and prefer sending appointment letters by email. Giving consent to us contacting the service user by email also enables their therapist to share important documents with them more freely.
Please enter their email address below if we can contact them by email.
Service user's email
What times and days would the service user prefer to be seen? We always aim to meet these requests wherever we can, but we are not always able to meet everyone's requests all of the time. In such cases, we will try and meet them as closely as we can.
Their religion
Required
African Traditional Diasporic Agnostic Atheist Baha i Buddhism Cao Dai Chinese traditional religion Christianity Hindiusm Islam Jainism Juche Judaism Neo-Paganism Nonreligious Primal-indigenous Rastafarianism Secular Shinto Sikhism Spiritism Tenrikyo Unitarian-Universalism Zoroastrianism Other
Their ethnicity
Required
White British White Irish Mixed White/Black African Mixed White/Black Caribbean Mixed White/Black Asian Asian Bangladeshi Asian Indian Asian Pakistani Chinese Black or British Caribbean Black or Black British African Other Asian Background Other White Background Other Black Background Other Mixed Background Other Ethnic Group
Their marital status
Required
Co-habiting Divorced/Civil partnership dissolved Married/Civil partner Widowed Separated Single
Their smoking status
Required
Non-smoker Current smoker Ex-smoker Never smoked
Details about their GP
The service user's GP must be in North East Lincolnshire. Any referrals outside of this area cannot be accepted. Please refer to the NHS website for details of your local NHS Talking Therapies provider.
Their GP practice
Required
Their GP's name
To help us triage this referral, please tell us about the problems that have brought the service user to seek talking therapy at this time.
Please consider telling us about:
A recent example of what they have been feeling and why — examples may include relationship breakdowns, loss of a job, poor self-esteem or worry
When did the feelings start and how long has this been going on?
What part of these feelings affect them the most?
What impact do the feelings have on their daily life?
How would they like things to be different?
What can we do to help the service user at this time? Is there anything they want to achieve, overcome or change?
A few details about access
If the service user has been diagnosed with any mental health problems or disorders, please state them here
Is the service user currently being seen by mental health services or have they been seen by them previously? If so, please provide a little detail about who they saw, when and what for.
Does the service user require an interpreter? If so, please state which language.
Does the service user require any reasonable adjustments to support them in accessing or attending the service? If so, please let us know what these are.
What is the service user's current accommodation status?
Required
Accommodation tied to job (including armed forces) Admitted patient setting Bed and breakfast Care home with nursing Care home without nursing Criminal justice settings Homeless Hostel Living with family Living with friends Mainstream housing Mobile accommodation Other Owner/occupier Shared ownership scheme Sleeping in a night shelter Specialist housing Specialist group home Temporary housing Tenant - location authority/registered social housing provider University or college accommodation Tenant - private landlord Staying with friends and family as a short term guest Sofa surfing Rough sleeper Squatting
Once this referral has been submitted, one of our reception team will be in touch with the service user to arrange an appointment.
If they are unable to get in contact with them initially, they will continue attempting to contact them for two weeks by the options you have chosen above.
If they do change your mind about wishing to see us, please contact us to let us know .
The information you send will be stored securely but you can read our full privacy policy for peace of mind .
Please note: we are currently experiencing a potential issue with online form submission on the Navigo website.
If you are struggling to submit this form, please call (01472) 625100.
