<p> B&NES Primary Care Talking Therapies Service Referral Form</p><p>REFERRER DETAILS Name of Referrer: Address:</p><p>Organisation of Referrer:</p><p>Contact Number: Date of Referral:</p><p>PATIENT DETAILS Surname: Gender: NHS No.:</p><p>Forename(s): Title: Date of Birth:</p><p>Telephone Number Can we leave a Telephone Number Can we leave a (home): message? Yes/No (mobile): message? Yes/No</p><p>Address: GP Surgery:</p><p>Postcode: Registered GP: Ethnicity: Current/Ex member of the army or reservists? Yes – current / Yes – Ex / No Disabilities: Please indicate if patient falls within these groups:</p><p>Veteran / Has A Child Under Five / Pregnant</p><p>Long term conditions:  Asthma  Coronary Heart Disease  Medically Unexplained  Arthritis  Dementia Conditions  High blood pressure  Insulin Dependent  Osteoporosis  Crohn’s disease Diabetes  Parkinson’s Disease  Cancer  Non Insulin Dependent  Severe Mental Health  Chronic fatigue Diabetes Problems  Chronic Kidney Disease  Eating Disorder  Stroke and Transient  Chronic Obstructive  Epilepsy Ischaemic Attack Pulmonary Disease  Fibromyalgia  Thyroid Problem  Chronic Pain  Hypertension  Other (please specify):  Chronic Muscular Skeletal  Irritable Bowel Syndrome  Chronic Pancreatitis  Multiple Sclerosis REFERRAL INFORMATION Reason for referral- PLEASE ATTACH CARE PLAN AND RISK ASSESSMENT :</p><p>Risk Information (Please provide any information about current or previous self-harm or suicide risks):</p><p>Previous contact with mental health services (please include any previous psychological therapy):</p><p>Any other relevant information (please include information concerning why the patient is unable to self-refer and how best for us to contact the patient):</p><p>OFFICE USE Date Received: IAPTUS No.:</p><p>Please fax this form to 01225 362799 or email to [email protected] or post to: BANES Primary Care Talking Therapies Service, Hillview Lodge, RUH, Bath, BA1 3NG. Guidance for BPCTTS Referrals</p><p>The majority of individuals self-refer into our service, they can do this by contacting our service directly on 01225 675150. We also offer a range of psycho-educational courses that can be booked directly through our website, http://iapt-banes.awp.nhs.uk. If a patient is able to self-refer, please provide them with a ‘working it out’ leaflet and encourage them to do so. </p><p>This referral form is for the minority of individuals who are unable to self-refer. Below is a list of people that we typically work with, as well as our exclusion criteria. If you are making a referral to our service, please ensure that the patient fits this criteria. If you are unsure you can contact our office and ask to speak to a duty practitioner.</p><p>People We Typically Treat Exclusion Criteria</p><p>• People who fit within the traditional IAPT • People who are at immediate or unstable framework – ie: mild/moderate anxiety risk (no consolidated period of stability) and/or depression AND • Main problem is an eating disorder and • Moderate/Severe anxiety disorders their BMI (Body Mass Index) indicates any and/or depression risk • People under the care of Specialist • People experiencing a current psychotic Mental Health Services episode • People who have a diagnosis of • Anyone under 16 yrs Personality Disorder or who may • People who present a risk to staff experience similar symptoms and are willing/able to engage in regular group • People using drugs or alcohol to a level treatment that would prevent them engaging in • People who use drugs or alcohol treatment • People with long term health conditions • People who are not stable enough to engage in a talking therapy • People with psycho-sexual difficulties • People wanting long term therapy • Bereavement • People under the care of Specialist Mental • Couples Health Services who are engaged in specialist psychological treatment with • Relational difficulties the Therapies Team • Stress</p><p>• Carers</p>