Referral Form Wakefield Righsteps

Rightsteps® Wakefield – Improving Access to Psychological Therapies Self Referral Form

Please take some time to complete the following information, the more information you give can help us ensure get you the right support as soon as possible.

Please note that we cannot provide an emergency service. If you need help urgently and are not confident you can keep yourself safe for the next 4 weeks, please consider contacting the following services:

 Samaritans: 0845 790 9090 (National) or 01924 377 011 (Local)  NHS Direct: 0845 46 47/ 111  Or call your GP and make an urgent appointment to see them. If they are closed an automated message will direct you to the Out of Hours GP.

Once you have completed this form please email it to us at: [email protected]

Or drop it in or send it in the post to: Rightsteps, 3rd Floor Grosvenor House, Union Street, Wakefield, WF1 3AE

Title: First Name (s): Surname:

NHS Number ( if known): Date of Birth: Ethnic Origin:

Nationality: You consent to us to sharing Confidentiality Statement Please can you identify any times information with your GP and Turning Point Rightsteps Wakefield Service over the next month you will be routine anonymous statistical keeps the information that you share with unable to attend for an data with the Dept of Health: us on a dedicated computer system to appointment e.g. holidays. ensure that it is stored safely and securely. Hospital appointments, childcare Do you agree to this? This is accessed and used by staff to plan etc and monitor your treatment. Information is shared with your GP and other NHS Yes No providers who need to be involved in your care to ensure that you receive the correct Please can you identify anyone treatment at the right time. On occasions you would like us to have we may also need to share information with permission be able to talk to about other professionals if you tell us something your therapy or book that leads us to believe that you or appointments with on your behalf: someone else is at risk of harming themselves or another person; if you inform Would you like adding to our us of a criminal activity or we have any “cancellation list” which would child protection concerns. Should this be the case we will endeavour to discuss this mean we may offer you an further with you and involve you in the assessment with as little as an process wherever possible. hour’s notice?

Do you agree to this? Yes No Yes No

Appendix C 1 Address: Postcode: Email address (if you have one):

Would you be happy for us to send you appointments via email? Yes No

Contact telephone numbers: Can we leave messages on these Can we say who we are & where numbers? we are from if we leave a message?

Where did you hear about GP Name GP Surgery Rightsteps?

Next of kin: First Language: Are you able understand written English? Relationship to you (partner, parent, etc.):

Their address: Are you able to read and write in your preferred language?

Their telephone number:

Relationship status (if you wish to Sexuality (if you wish to disclose): Religion (if you wish to disclose): disclose):

Do you have any long term health Do you have any mobility problems (i.e Any other professionals Involved conditions or disabilities? can you manage stairs, do you need e.g. counsellor, Community Mental wheelchair access)? Health Team. Psychology, Crisis Team:

Are you pregnant or have a child Have you ever served in the Armed Any other relevant information? under one? Forces?

Please describe your reason for referral (nature of the problem e.g. mood, behaviour):

Appendix C 2 History of presenting problem (Please give details of when you think this problem started):

Have you had any treatment from mental health services before? (If possible, give details of who this was with and when)

Current medication:

Any other relevant medical information:

Risk Assessment – Please note: If this section is not completed, we cannot process your referral. Please complete all that apply, details must be included in the boxes below: Now In the past Please give further details if you have (please circle) (please circle) ticked yes: I have thoughts of harming Yes No Yes No myself or taking my own life I am have I have acted on made plans these thoughts in to harm the past and myself: harmed myself/ attempted suicide:

Yes No Yes No

In an average week how much alcohol do you Do you currently use any drugs including recreational drugs drink? (i.e. Cannabis, ecstasy)? How often do you use these?

If it looks like we may be able to help you directly, the next step would be an appointment to find out more about your referral and goals. Please circle as many of the options below which you would be happy with for that one appointment:

Telephone Face to Face Online via videochat

Many thanks for your time. We will enter all of your details on our system, and will contact you as soon as we are able to offer you an assessment appointment. If we do not think that our service is the right service for you we will contact you within 72 hours to discuss the best way forward.

Appendix C 3