Referral Form

steps2change provides talking therapies for people experiencing problems with anxiety, depression, stress and offers help with issues like bereavement or the impact of a traumatic event.

Please note that steps2change Lincolnshire is for mild to moderate mental health problems and cannot provide an urgent/emergency service. If you feel you are at risk of harming yourself, or someone else please contact your GP or call 999 as a matter of urgency. You can also call NHS 111 for advice or the Mental Health Matters Helpline 24 hours a day for emotional support on 0800 001 4331

Title:*

First Name:*

Last Name:*

Date of Birth:*

Gender:*

Male

Female

Not specified

Not known

Marital Status:*

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Permission to send written communication via post?:*

Yes

No

Phone Number:

Phone Type:

Permission to leave voicemail?:

Yes

No

Mobile Number:

Permission to leave voicemail?:

Yes

No

Permission to send SMS text?:

Yes

No

Email Address:*

Permission to send email:*

Yes

No

GP Name:

GP Surgery Name:*

GP Surgery Address:*

GP Contact Number:

Permission to share information with GP:*

Yes

No

Language:*

Able to Communicate in English?:*

Yes

No

Interpreter required?:*

Yes

No

Ethnicity:*

Religious or Belief affiliation:*

Ex-British Armed Forces:*

Sexuality:*

Do you identify as the same gender you were assigned at birth?:*

Mobility issues?:*

Yes

No

Long Terms Medical Conditions:*

Does this condition have an impact on your mental health?

Yes

No

Disability:*

Please give brief details of why you wish to access steps2change. Can you describe the way that your problem impacts on your life, how long for have been experiencing this problem and any other information you feel we need to know?

Please give brief details of why you wish to access steps2change:*

Are you currently in receipt of any other form of therapy/seeing any other mental health professional e.g. CPN, psychologist, psychiatrist?:*

Yes

No

If yes, please give details:

Have you had any formal diagnosis from a GP, psychiatrist or other mental health professional?:*

Yes

No

If yes, please give details:

Are you currently taking any medication, which has been prescribed by a doctor?:*

Yes

No

If yes, please give details of medication prescribed:

Please complete the captcha

Self-referral Questionnaire

Personal Details

GP Details

Further Information

Referral Information