Client Led Referral Form      

Please note - This is not a self referral form - we hope this form can be completed collaboratively by client and referrer.

Gaps in information may result in delay in processing referral, it is particularly important that the referrer includes an up-to-date risk history.

Single Point of Access - Centre for Specialist Psychological Therapies
 

Part 1 - Referrer details

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Part 2

The following information needs to be completed by the person referring you to the service.    

Date
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Address Required
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Date of birth Required
Invalid date
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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

*We will take your request into consideration at Single Point of Access.  

Current difficulties:

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Previous psychological therapies

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Current ways of managing

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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

Medication

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Do you have any involvement with other services in addition to health?

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Social situation

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Additional information

Do you give permission for us to contact previous services (including Talking Therapies) to support the triage process? Required
Do you give us permission to contact you by phone to discuss your referral to our service further if necessary? Required
Required

Contact telephone no: 0191 287 6100