Referral Form

This self-referral form is an easy way for you to access psychological support and advice from Milton Keynes Talking Therapies Service (IAPT). The service is open Monday to Friday 9am until 5pm.

Having thoughts and feelings of hopelessness can be normal when you are feeling depressed. However, we are not able to provide immediate help and support if you are feeling suicidal or in crisis. If you need immediate help please contact your GP, your local Accident and Emergency (A&E) department, or call the emergency services on 999.

If you complete this form and we are concerned for your safety we will complete a referral to Crisis Services. We would usually try to contact you by telephone beforehand.

NHS Number (if known):

Title:*

First Name:*

Last Name:*

Date of Birth:*

Gender:*

Male

Female

Other

If other, please specify your gender identity here:

Disability Status:*

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Home Number:

Permission to Leave Voicemail?:

Yes

No

Mobile Number:

Can we send you text message reminders?:

Yes

No

Permission to Leave Voicemail?:

Yes

No

Email:

Permission To Send Questionnaires By Email?:

Yes

No

GP Practice Name:*

GP Practice Address:*

National Identity:*

Ethnicity:*

Religious Group:*

Preferred Language:*

Relationship Status:*

Sexuality:*

Long Term Condition Status (e.g. cancer, diabetes, heart disease, stroke):*

If yes, please specify:

Have you ever served in the British Armed Forces?:*

Are you currently pregnant or have a child under the age of 24 months?:*

Yes

No

Emergency Contact Name:*

Emergency Contact Number:*

Please describe the problems that you are experiencing that you would like us to help with:*

Please describe when you think your problem first started:*

Please describe any mental heath support you are having or have had for your difficulties in the past:*

Where did you hear about this service?:*

Do you currently have any thoughts of harming yourself or suicide?:*

Yes

No

Do you have any current plans to act on these thoughts?:*

Yes

No

Have you ever planned or attempted to end your own life?:*

Yes

No

By completing and submitting this form you are consenting for your information to be stored on our confidential service database. This information is held securely and is not viewed by anyone outside of Central and North West London NHS Foundation Trust. More information can be found here: https://mktalkingtherapies.nhs.uk/about-us/your-information.

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Self-referral Form

YOUR DETAILS

GP DETAILS

FURTHER INFORMATION

EMERGENCY CONTACT DETAILS

REFERRAL INFORMATION