Self referral form | NHS Manchester Talking Therapies (The Big Life group) self-referral form

NHS Manchester Talking Therapies (The Big Life group) self-referral form

We provide support to people aged 18 or above who are registered with a Manchester GP.

We provide support for common mental health conditions, such as anxiety or depression, including: counselling, cognitive behavioural therapy, mindfulness, or guided online therapy.

The service is delivered by a range of professionals including psychological wellbeing practitioners (PWPs) and counsellors, who will find the support that is right for you. This could be a group workshop, an online or telephone based course of self-help treatment, or an individual therapy session.

To help us put you in touch with the team who can give you the support you need, please complete the form below. Where possible, we will send correspondence to your email address to reduce our carbon footprint. If this suits, please remember to provide consent to contact you by email.

Please note: this service is not a crisis service and will not be suitable for you if you are at immediate or imminent risk to yourself or others.
If you feel that you are in distress, for example if you feel at risk of harming yourself or others then we would urge you to contact any of the following organisations who are able to offer support:
NHS (non-emergency) 111 (24hrs)
Samaritans (Helpline) 116 123 (24hrs)
Alternatively, please contact your GP. Or if in crisis, attend your local A&E department

(you may wish to call an ambulance on 999)

If you want to find more about how we use your information, please see this page to view our terms and conditions:

https://www.selfhelpservices.org.uk/Privacy/

The Talking Therapies pathway is delivered by The Big Life group in partnership with the Greater Manchester Mental Health NHS Foundation Trust.

If for anyone reason this referral form is being filled out by a third party, please note that the client must have consented to the referral being made and that information included on the form may be shared with the client.

* Indicates a required field

Your Details

Title *

First Name *

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Last Name *

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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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Post Code *

Do you provide consent for us to send correspondence to this address? *

Yes No

Date of Birth *

Gender Identity *

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

Accommodation Type *

NHS Number (if known)

*Must be a valid NHS number

We will try to contact you by telephone unless otherwise advised. If possible please provide a mobile number in addition to a landline.

Mobile Phone Number

Do you provide consent for us to contact you on this number? *

Yes No

Do you give: Consent to leave a voicemail on your mobile phone number? *

Yes No

Do you give: Consent to receive SMS reminders on your mobile phone number? *

Yes No

Home Phone Number

Do you provide consent for us to contact you on this number? *

Yes No

Do you give: Consent to leave a voicemail on your home phone number? *

Yes No

Email Address *

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Do you give: Consent to receive emails?
(If provided, you will receive first contact to your email address. Remember to check your junk folder) *

Yes No

Next of Kin Name

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Next of Kin Address

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Next of Kin Telephone number

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Relationship to you

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Your GP Details

GP Surgery *

We are required to notify your GP that you are accessing our service. Please provide permission for us to write to your GP with this information.

Do you give consent for your GP to be contacted? *

Yes No

Where did you hear about us? *

Presenting Problem

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

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Do you have any thoughts of ending your life? *

Yes - (If Yes, please can we direct you to the highlighted section at the top of the referral page)
No

Do you think you might act on these thoughts? *

Yes - (If Yes, please can we direct you to the highlighted section at the top of the referral page)
No
N/A - I do not have any thoughts of ending my life

Are you currently experiencing domestic abuse? (if at any risk, please contact womens aid/police as necessary)

Yes No

About you

Marital Status *

Sexual Orientation *

Ethnic Origin *

Religion *

Main Language *

Is an interpreter required?

Yes No

Do you have any problems speaking, reading or writing English? *

Yes No

If Yes please give details

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Do you have any Disability? *

Do you have any Long Term Conditions? *

Do you have a neurodiverse condition?

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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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? *

Yes No

I would like to receive a confirmation of the referral to the email address I specified above. Please check the spam folders within your email if you do not receive a confirmation in your inbox.

I accept terms and conditions. *

Incomplete information

Terms and conditions

Please tick the checkbox to accept the terms and conditions.

An unexpected error occurred

An error occurred with data entry

There was a problem sending these details.
Please check for invalid characters such as quotes (’ ‘ ´ `) and long dashes (– —) in any text you may have typed or pasted in, and try again.

If the problem persits, then please contact your service.

Important Service Message

Important Service Message

Contact Telephone: 0161 226 3871

Contact Email: manchestertalkingtherapies@thebiglifegroup.com