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First Name (required)
Date of Birth (required)
Address 1 (required)
Can we contact you via the address given? (required)
Please be aware that a clinician will call you to discuss your referral. The call will show as a withheld number. If we can’t speak to you, it may result in your referral not being processed. If we can’t contact you, we will contact your GP.
Mobile Phone Number
Can we text you on this number?
Can we leave a voicemail on this number?
Telephone Number 2
Your Email (required)
Can we contact you using the email given?
GP Surgery (required)
Name of GP, if known
Do you need an interpreter? YesNo
If you require an interpreter, which language is needed? (required)
Have you had any contact with any other mental health services in the past 12 months?(required)YesNo
If yes, click all that apply
Community mental health teamDrug or alcohol servicesCrisis teamPsychology servicesEarly Intervention in Psychosis TeamEating Disorders ServiceOther IAPT serviceOther
Are you pregnant? (required) YesNo
Have you given birth within the last 12 months? (required) YesNo
Are you a military veteran? (required) YesNo
Please tick any of the following common issues which are the reason for your referral: (required)
Low moodPanicDepressionAnxietyStressFamily ProblemsTraumaHealth AnxietyObsessive Compulsive DisorderBereavement or lossRelationship difficultiesAngerOther
If we decide that we are not the right service to offer you support, we may send your referral to another service that may be more appropriate for you. We would always endeavour to contact you to discuss this with you first where possible. Please confirm that you have read and understood this.(required) Agreed
If we have concerns about the safety of anyone accessing our service, we have a duty of care to liaise with appropriate health and social professionals to ensure the necessary support is arranged. Please confirm that you have read and understood this. *.(required) Agreed
By submitting this form, you consent to your information being shared with Insight Healthcare. This information is handled confidentially, in accordance with the Data Protection Act 2018. Agreed
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