Self-refer to NHS Talking Therapies

Male therapist NHS Talking Therapies smiling after self referral

We need to get some information from you so we can register you with NHS Talking Therapies.

Completing the form below doesn’t automatically mean you’ve been accepted, but the team will be in touch to discuss the next steps within a week. If you’re in need of more urgent help, contact the Single Point of Access.

First, there are a few things we need to make sure you’re aware of:

You must be at least 16-years old and registered with a GP in North East Lincolnshire
We securely store the information you give us, but if you’re worried you can also read our full privacy policy to put your mind at rest
If you’re already getting support from another mental health team – for example, the community mental health team – NHS Talking Therapies might not be the right service for you
If you have a severe mental health problem such as schizophrenia or a personality disorder, NHS Talking Therapies isn’t the right service for you
If your main issues are due to alcohol or drug use, NHS Talking Therapies might not be for you. Visit the Navigo Hub for support and signposting
NHS Talking Therapies is not a crisis service, so contact the Single Point of Access if you need help urgently.

Okay to carry on? Great.

Are you a healthcare professional looking to refer someone else into NHS Talking Therapies? Please complete the NHS Talking Therapies professionals referral form instead.

Self-refer to NHS Talking Therapies

A few details about you

Title Required

Miss

Mrs

Sir

Full name Required

If you've been known by any other names, please state them here.

First line of your address Required

Postcode Required

Date of birth Required

Mobile number

Home telephone

Can we leave a voicemail message? Required

Yes

We send out text reminders of appointment times two days beforehand. Can we contact you via text message?

Yes

Can we leave a message with a friend or family member? Required

Yes

You 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 you by email also enables your therapist to share important documents to you more freely.

Please enter your email address below if we can contact you by email.

What is your preferred method of contact? Required

Text

Telephone

Letter

No preference

What is your preferred consultation method? Required

Face-to-face

Telephone

Video (via Microsoft Teams)

Where would you like to be seen? We try and accommodate your request, but alternative locations may also be offered. Required

Navigo House

Weelsby View Health Centre

Raj Medical Centre

Freshney Green Primary Care Centre

Anything Goes (Cleethorpes Boating Lake)

Grimsby Institute

Grimsby Leisure Centre

YMCA (Freeman Street)

Waltham Library

What times and days would you 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 possibly can.

Your religion Required

Your ethnicity Required

Your marital status Required

Your smoking status Required

Where did you hear about us? Required

GP or other healthcare professional

Another Navigo service

Search engine (e.g. Google)

Leaflet or poster

Social media

Family or friend

Other

Please complete this section if we can have the details of someone to contact in case of emergency.

Their name

Their contact number

Their relationship to you

Details about your GP

Your 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.

Your GP practice Required

Your GP's name

Were you advised by your GP to refer to NHS Talking Therapies? Required

Yes

Would you be happy for your GP to know about this referral? Required

Yes

To help us triage your referral, please tell us about the problems that have brought you to seek talking therapies at this time.

Please consider telling us about:

A recent example of what you 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 you the most?
What impact do they have on your daily life?
How would you like things to be different?

What problems can we help with you with at this time? Is there anything you want to achieve, overcome or change?

A few details about access

If you have been diagnosed with any mental health problems or disorders, please state them here.

Are you currently being seen by mental health services or have you been seen by them previously? If so, please provide a little detail about who you saw, when and what for.

Do you require an interpreter? If so, please state which language.

Do you require any reasonable adjustments to support you in accessing or attending the service? If so, please let us know what these are.

Do you have parental responsibility? Required

Yes

Are you currently in receipt of statutory sick pay? Required

Yes

I would prefer not to answer

Are you currently in receipt of benefits?

Yes

I would prefer not to answer

Are you currently in settled accommodation? Required

Yes

I would prefer not to answer

What is your current accommodation status? Required

Once this referral has been submitted, one of our reception team will be in touch with you to arrange an appointment.

If they are unable to get in contact with you initially, they will continue attempting to contact you for two weeks by the options you have chosen above.

If you do change your mind about wishing to see us, please contact us to let us know.

Privacy notice

The information you send will be stored securely but you can read our full privacy policy for peace of mind.

Privacy notice Required

I agree to the terms of the privacy notice

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.

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