Self Referral Form

Step 1 of 7
Name
Email Address
Address
Postcode
Date of Birth
Home telephone number
Can we leave a message on this number?
Mobile telephone number
Can we leave a message on this number?
Best day and time to ring
Gender
Marital Status
Other Relevant Information
GP Surgery
If your surgery does not appear on the list above please call 01332 265659 for information about your local IAPT service.
GP Name
Nationality
NHS Number
Where did you hear about us?
Step 2 of 7
Give brief details of the nature of the problem
Give brief details of how long the problems have been present and how they have changed over time:
Give brief details of any previous or current treatment for the problems including involvement of the Mental Health Service, Psychiatrist, or psychological therapies:
Give details of current medication and when this was started:
Please state the expectations of psychological therapy:
Recent or previous acts of self-harm:
(If yes, please give details and date of last act of self-harm):
Recent or previous suicidal impulses or plans:
(If yes, date last experienced these):
Current drug or alcohol problems:
(Please give details):
History of violence:
(Please give details):
Current physical problems & treatment: (Please give brief details):
Step 3 of 7
Over the last 2 weeks, how often have you been bothered by any of the following problems?
  Not at all Several days More than half the days Nearly every day
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 you 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
Step 4 of 7
Over the last 2 weeks, how often have you been bothered by any of the following problems?
  Not at all Several days More than half the days Nearly every day
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
Step 5 of 7
Choose a number from the scale below to show how much you would avoid each of the situations or objects listed below. Then write the number in the box opposite the situation.
0 1 2 3 4 5 6 7 8
Would not avoid it   Slightly avoid it   Definitely avoid it   Markedly avoid it   Always avoid it

Social situations due to fear of being embarrased or making a fool of myself
Certain situations because of a fear of having a panic attack or other distressing symptoms (such as loss of bladder control, vomiting or dizziness)
Certain situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in confined spaces, driving or flying)
Step 6 of 7
Please indicate which of the following options best describes your current status:
Employed full-time (30 hours or more per week)
Employed part-time
Unemployed
Full-time student
Retired
Full-time homemaker or carer
Are you currently receiving Statutory Sick Pay?
Are you currently receiving Job Seekers Allowance, Income support or Incapacity benefit?
Step 7 of 7
People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems look at each section and determine on the scale provided how much your problem impairs your ability to carry out the activity.
1. WORK - if you are retired or choose not to have a job for reasons unrelated to your problem, please tick N/A (not applicable)
Not at all   Slighty   Definitely   Markedly   Very severely,
I can't work
2. HOME MANAGEMENT - Cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc
Not at all   Slighty   Definitely   Markedly   Very severely
3. SOCIAL LEISURE ACTIVITIES - With other people, e.g. parties, pubs, outings, entertaining etc.
Not at all   Slighty   Definitely   Markedly   Very severely
4. PRIVATE LEISURE ACTIVITIES - Done alone, e.g. reading, gardening, sewing, hobbies, walking etc.
Not at all   Slighty   Definitely   Markedly   Very severely
5. FAMILY & RELATIONSHIPS - Form and maintain close relationships with others including the people that I live wit
Not at all   Slighty   Definitely   Markedly   Very severely