Self referral form | Gaddum Therapy

Details of referrer

Please indicate who is making this referral *

If this is a professional referral, please state the name, role and contact details of the referrer and the relationship to individual being referred.

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Has the referral been discussed with and agreed by the client/patient? Please note we cannot accept a referral without this consent. *

I confirm the person I am referring gives permission for you to discuss details of their referral with me

Details of the person being referred to Gaddum

Title *

First Name *

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Last Name *

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Date of Birth *

Address Line 1 *

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Address Line 2

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Address Line 3

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Town/City *

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County

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Post Code *

GP Surgery *

Name of out of area GP surgery

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NHS Number

Contact information and availability

Home Phone Number

Can messages be left?

Yes

No

Mobile Phone Number

Can messages be left? *

Yes

No

Does client give: Consent to receive SMS communication including appointment reminders on this mobile phone number? *

Yes

No

Email Address

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Does client give: Consent to receive emails?

(Remember to check the junk folder) *

Yes

No

We usually make initial contact with you via telephone unless you tell us otherwise. Please indicate the best time to contact you.
Please note we are open from 9am-5pm.

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Accessibility information

Preferred Language *

Please let us know of any adjustments you may need to enable you to access the service e.g. wheelchair access to venues, large text on letters, a specific form of contact

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Are there any other specific needs or requirements you need us to be aware of?

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About you

This information is used for monitoring purposes and to signpost service users to relevant services

Any information given should be determined by the person being referred, given voluntarily, and will be stored confidentially in line with data protection laws.

Gender *

Is your gender the same as your gender assigned at birth?

Ethnicity *

Faith or Religion *

Sexual Orientation *

Have you ever served in the British Armed Forces or are a dependent of someone serving? *

Are you or your partner expecting a child, or have a child under 24 months? *

Disability *

About your referral

Please provide a brief summary of your problem and reason for your referral. (Please include how long you have experienced your problem and if you have received any previous treatment) *

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Prescribed medication *

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Any other Services Involved with: (Please be aware this includes social workers, parole officers, psychiatrists etc) *

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How did you hear about our service?

Are you experiencing any issues related to the below? Please provide details where possible

Severe mental health issues: psychosis, hearing voices, hallucinations

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Suicidal Ideation

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Involvement with other mental health agencies

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Drug or alcohol misuse

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Social or domestic problems

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Please provide further details about the above or any other risk issues (if relevant)

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Consent for referral

For self-referrals:

Do you consent to this referral, and being contacted via any of the contact methods provided on this form ?

Yes

No

Consent gained by referrer:

Does the person being referred consent to the referral and consent to being contacted via any of the contact methods provided on this form (including text appointment reminders)?

Yes

No