See a Psychological Wellbeing Practitioner

Psychological Well Being & Primary Care Mental Health Services Self Referral Form

Items marked with * are required

Gender*

Date of Birth*

Contact Details

How may we contact you? (Hold Ctrl to select more than one)*

GP Details

Referral Details

Reason for referral (Please outline the problem, how long have you been experiencing problems and how it has impacted on work, family and your social life. Please highlight if you are pregnant, in the post natal period (1 year following birth) or have served with HM Armed Forces and if your reason for referral is linked.)*

Have you ever been referred to or accessed psychological or talking therapies? (If yes give details)

Have you ever been referred to or accessed secondary mental health services? (If yes give details)

Are you currently prescribed any medications for mental health problems? (If yes give details)

The service offers COMPUTERISED and GROUP Therapy. Please secify below any reasons why you could not access either of these:

Please tick any specific needs which we may have to take account of (Hold Ctrl to select more than one):

We are required to notify your GP that you are accessing this service. Please tick the box to give permission to write to the GP with this information:*

Demographic Information (IAPT Minimum Data Requirements)

Employment

Are you currently receiving any of the following benefits (Hold Ctrl to select more than one):

Which option best describes your current accomodation:

Ethnicity

Religion

4 + 5 =*

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