Part 1
Date
Name
* Required
Preferred name
* Required
Pronouns
Address
* Required
Telephone number
* Required
E-mail address
* Required
Date of birth
* Required
NHS number
Ethnicity
* Required
Next of kin
* Required
GP address and details
* Required
Care Co-Ordinator/ Other services involved (if any):
Care Co-Ordinator Contact Telephone Number
Psychological Therapy:
Within the Centre, we offer a range of Psychological Therapies. If you require further information about these, please contact cspt@cntw.nhs.uk .
If you know what therapy, you would like to engage with from the options below please tick the relevant box.
Please select which therapy* you are requesting:
* Required
CAT (Cognitive Analytic Therapy)
CBT (Cognitive Behavioural Therapy)
Psychotherapy
IPT
EMDR
*We will take your request into consideration at Single Point of Access.
Current difficulties:
Please could you tell us what you are struggling with?
* Required
It can be helpful to know, when this started and how it affects you?
* Required
Do you need any support or adjustments that would help you get the most out of therapy? (e.g., physical health, mobility, or visual impairments, how do you get to your appointments? e.g. are you able to drive or do you use public transport)
* Required
What are you hoping for from any treatment offered: “I would like help with…”
* Required
Previous psychological therapies
Can you tell us about any previous therapy, including the therapy/target problem, how long it was for, when it ended, and if it was helpful (Y/N)?
* Required
Current ways of managing
Please can you describe any recent or past events, which you or others consider risky and/or dangerous?
* Required
Do you use alcohol or drugs to help you manage your current difficulties?
* Required
Have you ever done so in the past? If so, when?
* Required
Childhood and personal history
Is there anything from your own childhood personal experience that you think is influencing your current difficulties or important to share?
* Required
Yes
No
Can you say more?
Medication
Please include any relevant medication which we need to be aware of in relation to managing a mental health or physical health condition?
* Required
Do you have any involvement with other services in addition to health?
This may include court proceedings, probation services, third sector organisations, police, children’s/adult services etc.
* Required
Social situation
Can you please tell us a little about who you would consider to be supportive in your life and any significant relationships?
* Required
Additional information
Is there anything else you feel it would be important for us know?
Do you give permission for us to contact previous services (including Talking Therapies) to support the triage process?
* Required
Yes
No
Do you give us permission to contact you by phone to discuss your referral to our service further if necessary?
* Required
Yes
No
If yes on what number?
Are there any times you wish us to avoid?
Part 2
The following information needs to be completed by the person referring you to the service.
Name
* Required
Service
* Required
Contact number
* Required
E-mail address
* Required
Role and relationship to person being referred to the service
* Required
Please can you include any relevant additional information – this may include relevant risk history/previous psychiatric admissions.
* Required
