A few details about you
Full Name
Required
If you have been known by any other names, please state them here
First line of your address
Required
Postcode
Required
Mobile telephone number
Required
Home telephone number
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 with you more freely.
Please enter your email address below if we can contact you by email.
Email
Sexual orientation
Required
Heterosexual Gay Lesbian Bisexual Other Prefer not to answer
Religion
Required
African Traditional Diasporic Agnostic Atheist Baha i Buddhism Cao Dai Chinese traditional religion Christianity Hinduism Islam Jainism Juche Judaism Neo-Paganism Nonreligious Rastafarianism Secular Shinto Sikhism Spiritism Tenrikyo Unitarian-Universalism Zoroastrianism primal-indigenous Other
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
Marital Status
Required
Co–habiting Divorced/Civil partnership dissolved Married/Civil partner Widowed Separated Single
Employment Status
Required
Full-time employment 30+ hours/week Part-time employment Full-time homemaker/carer Long term sick or disabled, receiving incapacity benefit, Income Support or ESA Not receiving benefits and not seeking work Unemployed and seeking work Unpaid voluntary work and not seeking paid work Unpaid voluntary work and seeking paid work Retired Full-time student
Smoking Status
Required
Non-Smoker Current Ex-Smoker Never Smoked
Please complete this section if we can have the details of someone to contact in case of emergency.
Name
Contact Number
Relationship
Details about your GP
Your GP must be within North East Lincolnshire. Any referrals outside of this area cannot be accepted by NHS Talking Therapies.
GP Practice
Required
GP Name
To help us triage your referral, please tell us about the problems that have brought you to seek talking therapy 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 have brought you to seek talking therapy?
What can we do to help you 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.
If you have any disabilities, please state them here.
Once your application has been submitted, one of our reception team will be in touch with you shortly 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 .
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.
