Self referral form | NHS Oldham Talking Therapies

NHS Oldham Talking Therapies

NHS Oldham Talking Therapies service is for people over the age of 16 years, who are registered with a GP in the Oldham area.

If you are currently receiving treatment from a specialist mental health service (such as a community mental health team) or are accessing therapy through somebody else, please speak to your care coordinator or therapist about additional support.

Everyone referred to NHS Oldham Talking Therapies is invited to attend a group seminar to introduce them to our service. This is so that people can then make an informed choice about whether they would like to like to proceed with an assessment for NHS Oldham Talking Therapies.

Please note all fields marked with * are mandatory.

If we have identified any concerns for your safety or that of others, we have a legal duty to share this with relevant agencies.

Please be aware that our service is unlikely to be suitable for you if you are at immediate or imminent risk to yourself or others. Please see this page to see how you can access support. Crisis numbers - Oldham.

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* Indicates a required field

After attending your initial telephone assessment, please select your preferred method to attend your future sessions *

NHS Number

Title *

First Name *

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Last Name *

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Date of Birth *

If you are happy for us to communicate by e mail please enter your e mail address

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Consent for confidential emails

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 *

Home Phone Number *

Voice Mail Home *

Yes

Accommodation Type *

Mobile Phone Number *

Voice Mail Mobile *

Yes

We will contact you via SMS text message to provide therapy appointments and reminders. Do you agree for us to contact you in this way?

Yes

Is an interpreter required? *

Yes

Ethnicity *

Please select your gender *

First Language *

Please select your GP surgery *

Reason for referral *

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Please state how you heard about us *

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Have you been living in the UK for the last 12 months?

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

Are you a current or previous member of the military services? *

Do you have any difficulties with your current employment or require support to find employment? *

Next of Kin Name *

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Next of Kin Contact Number *

Child 1

First Name

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Last Name

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Date Of Birth of Child

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Relationship of Child to you

Child 2

First Name

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Last Name

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Date Of Birth of Child

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Relationship of Child to you

Child 3

First Name

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Last Name

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Date Of Birth of Child

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Relationship of Child to you

Child 4

First Name

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Last Name

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Date Of Birth of Child

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Relationship of Child to you

I accept terms and conditions. *

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