Please Return This Form to the Following Freepost Address

Please Return This Form to the Following Freepost Address

Hertfordshire Partnership University NHS Foundation Trust
Professionals Referral to WELLBEING (IAPT/CBT) services
Primary care services for mild to moderate mental health issues / Case Number:
Date Received:
Has the patient consented to this referral? Yes / No
Referral Source / Patient Details
Name

GP

Hospital Doctor

Specialist Nurse
Other colleague, please specify / Name
Address
Postcode
Date of Birth / Gender
NHS No. / Title
Initial contact will be made by telephone:
Landline number
GP Details / Mobile number
GP Name / Is it okay to leave a message on these numbers? / Yes / No
Any additional contact information/ Is client currently pregnant or do they havechildren under the age of 2
GP Surgery
Presenting Problem(Please tick all that apply and give brief details in the box below) / Other issues(Please tick all that apply)
Depressive episode / Obsessive compulsive disorder / Social isolation
Anxiety / Post traumatic stress disorder / Debt
Panic / Agoraphobia (with or without panic) / Employment
Bereavement / Social phobias / Relationship
Abuse / Specific phobias / Housing
Date of onset current episode:
Has the client had CBT previously? Yes/No
Has the client had contact with mental health services previously? Yes/No
If Yes please elaborate below.
Additional information
Past mental health history / Current medication / Physical health
Do you currently feel the patient a risk to themselves / Yes / No
Do you currently feel the patient is a risk to others / Yes / No
Do you currently feel the patient is at risk from others / Yes / No
If you have answered yes to any of the above , please give details:
Any other info. (E.g. interpreter required, special needs etc.)

Please return this form to the following freepost address:

Freepost RTHZ-XTSC-BXKC

The Single Point of Access,

Wellbeing Service Referral,

Hertfordshire Partnership University NHS Foundation Trust

99 Waverley Road

St Albans

AL3 5TL

Alternatively, you may fax referrals to:0300 777 0808 or email it to:

Information about our service can be found at:

Patient Information

The Wellbeing Servcie offers psychological help and practical support for people experiencing anxiety, depression and other common mental health problems. Many of the options that we offer are based on cognitive behaviour therapy (CBT) which has shown through research to be an effective psychological therapy for people experiencing anxiety or depression. CBT involves looking at the way you think and your ways of coping in order to identify changes that you can make that may help you to feel better.

There are a number of options depending on your particular requirements. These include attending a course on dealing with anxiety and depression, doing on line computerised CBT which you can access via any internet connection, following guided self help with a mental health practitioner either over the phone or face to face as well as individual CBT.

Patients if requiring individual sessions are seen in their own GP surgery, or in another appropriate setting in the local community. A range of different professionals work within the service including psychologists, cognitive behaviour therapists and psychological wellbeing practitioners.

Confidentiality and Risk

We ensure that the confidentiality of patients seen within the Wellbeing Service is protected. Information is recorded on a computer system which can be accessed only by relevant staff within the NHS Trust. With your permission we would usually share information with your GP and other health professionals involved in your care. We do share information on a need to know basis with other health and social care professionals in situations where there is felt to be a serious risk to yourself or others.

If you are concerned you are at risk of harming yourself, please contact your GP for an emergency appointment. If your GP is unavailable you can call the Single Point of Access on 0300 777 0707.

Cancellations and missed appointments.

We understand that there can be many reasons why you may not be able to attend your appointment. Please let us know as soon as possible if you need to cancel your appointment so that this time can be offered to someone else. Regular attendance for therapy sessions is an important aspect of your treatment. If there are more than two cancellations in your course of treatment, your therapist will discuss with you whether continuing therapy at that time would be beneficial.

If you miss your appointment without letting us know your therapist will contact you by phone or by letter giving you 5 working days to contact us to discuss any difficulties you might be having in attending. If we do not hear from you, we will assume that you no longer want an appointment and will discharge you from the service. However, you are welcome to refer yourself again in the future when you are ready for treatment.