We Aim to Help You To

Psychological Wellbeing Service (IAPT) Single Point of Access

Self Referral Form

Who are we? The Psychological Wellbeing Service (IAPT) teams based in Peterborough, Fenland, Huntingdon and Cambridge are there to help people manage common mental health problems such as anxiety and low mood which can create difficulties in a person’s everyday life. We accept self referrals from people over the age of 17 and who reside within Cambridgeshire or are registered at the Wansford and Kingscliffe Practice and Oundle Medical Practice.

We aim to help you to:

 Better understand your current problem and what is maintaining it.

 Explore how what you think and how you behave interacts with how you are feeling.

 Agree what you want to improve and to develop new ways of thinking, behaving and feeling.

 Agree goals to help improve your quality of life.

Help is offered in different ways:

 Workshops and courses

 Self help with printed material or on line

 Telephone or individual face to face sessions

The next step : Complete the form below and post, email or send it by fax to: The Psychological Wellbeing Service (IAPT) SPA. Grebe House, Gloucester Centre, Morpeth Close, Orton Longueville, Peterborough. PE2 7JU

Email: [email protected] Temporary Fax: 0845 045 0121 or complete a self referral online at www.cpft.nhs.uk

Please note that unless you are sending an email from an encrypted system, this method of communication may not be secure. If you have any concerns about emailing it back to us, please post to the above address.

Self Referral line: 0300 300 0055 Mon – Fri, 9am – 5pm (if you would prefer to speak to us to make your referral) First Name(s) Title Family Name Gender Date of Birth Ethnicity NHS number Marital Status Address

Email Address Contact number Mobile: Landline: Can messages Mobile: YES/NO Landline YES/NO be left Your GP’s name Surgery Name & Address

Private & Confidential Page 1 12/08//15 Is your GP aware of this referral? YES/NO If no may we advise your GP of this referral? YES/NO Do you consent to your medical records being viewed YES / NO Nationality? Do you need an interpreter? YES/NO If yes please state language required: Are you a UK Armed Forces Veteran: YES/NO Currently serving: YES/NO Veteran or currently serving? Name Date of birth

Are you pregnant or have you given birth within the past year? Are you a health care worker? YES/NO give brief details What is your main difficulty and how long has this been a problem? Please specify

Have you received or are you currently receiving treatment for this problem? YES / NO If yes please give details

Have you ever had thoughts of or have you tried to harm yourself in any way? YES / NO If yes please give details

Do you have any issues with alcohol or recreational drugs? Past YES / NO Current YES / NO If yes please give details

Are you currently taking any medication? YES / NO If yes please provide details

Do you have any ongoing or long term physical health problems e.g. asthma or diabetes? YES / NO If yes please provide details

Do you have any disability or mobility difficulties? YES / NO If yes please give details?

Please tell us about what you are hoping to gain from our service and what your goals are. You can use a separate sheet if required

Private & Confidential Page 2 12/08//15 PLEASE COMPLETE THE QUESTIONNAIRES ON THE NEXT TWO PAGES AND SEND THEM WITH YOUR REFERRAL

Private & Confidential Page 3 12/08//15 Name Date of birth

IAPT Employment Questionnaire

Please tick which of the following options best describes your status Employed Full-Time Unemployed (seeking work) Student (full time) Employed Part time Unemployed Student (part time) Self Employed Benefits Homemaker Retired Volunteer Are you currently receiving Statutory Sick Pay? Yes No Don’t know Are you suitable for or do you feel you would benefit from receiving employment support? Yes No

How did you find out about our Service?

PHQ-9 (Please tick the box next to each of your answers)

Over the last 2 weeks, how often have you been bothered by any of Not at all Several More than Nearly the following problems: days half the every day days (0) (1) (2) (3) 1.Little interest or pleasure in doing things 2.Feeling down, depressed, or hopeless 3.Trouble falling or staying asleep, or sleeping too much 4.Feeling tired or having little energy 5.Poor appetite or overeating 6.Feeling bad about yourself – or that you are a failure or have let yourself or your family down 7.Trouble concentrating on things, such as reading the newspaper or watching television 8. Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual. 9. Thoughts that you would be better off dead or of hurting yourself in some way. P HQ-9 Total Score (staff use)

GAD-7 (Please tick the box next to each of your answers)

Over the last 2 weeks, how often have you been bothered by any of Not at all Several More than Nearly the following: days half the every day days (0) (1) (2) (3) 1.Feeling nervous, anxious or on edge 2.Not being able to stop or control worrying 3.Worrying too much about different things 4.Trouble relaxing 5.Being so restless that it is hard to sit still 6.Becoming easily annoyed or irritable 7.Feeling afraid as if something awful might happen G AD-7 Total Score (staff use)

Private & Confidential Page 4 12/08//15 Name Date of birth

Work & Social Adjustment

Please look at the questions below and give a number between 0 and 8 to describe how much your problems affect you in each area. Work/ Education: if you are retired or choose not to have a job for reasons unrelated to your problems please circle N/A 0 1 2 3 4 5 6 7 8 Not at all affected Very severely affected Home management : cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc. 0 1 2 3 4 5 6 7 8 Not at all affected Very severely affected Social Leisure Activities: with other people- e.g. parties, pubs, outings, entertaining etc. 0 1 2 3 4 5 6 7 8 Not at all affected Very severely affected Private leisure Activities: done alone e.g. reading, gardening, sewing, hobbies, walking etc. 0 1 2 3 4 5 6 7 8 Not at all affected Very severely affected Family & Relationships : form & maintain close relationships with others including the people that I live with 0 1 2 3 4 5 6 7 8 Not at all affected Very severely affected Total W&SAS Score (staff use)

IAPT Phobia

Please choose a number from the scale below to show how much you would avoid each of the situations for the reasons given: Social situations because I fear being embarrassed or making a fool out of myself 0 1 2 3 4 5 6 7 8 Would not avoid Would always avoid Certain situations because I fear having a panic attack or other distressing symptoms (such as loss of bladder control, vomiting or dizziness) 0 1 2 3 4 5 6 7 8 Would not avoid Would always avoid Certain situations because I fear particular objects or activities (such as animals heights, seeing blood, being in confined spaces, driving or flying) 0 1 2 3 4 5 6 7 8 Would not avoid Would always avoid Total Phobia Score (staff use)

Thank you for taking the time to complete the self-referral form and the questionnaires. If required a member of our team may contact you to discuss your referral further. Please note that unless you are sending the email from an encrypted system, this method of communication may not be secure. If you have any concerns about emailing it back to us, please post to the above address.

Important note: We are not an emergency service and are unable to provide help should you require immediate support in a crisis situation. If you do require more urgent support please discuss your referral with your GP as soon as possible. You may also contact the following:

The Samaritans 08457 909090 Urgent Care Cambridgeshire dial 111

Private & Confidential Page 5 12/08//15 Lifeline 08088 082121 (7pm -11pm 365 days a year) Your local Emergency Department / A&E

Private & Confidential Page 6 12/08//15