Recite - Accessibility and Language Options

Self referral means you don't have to see your GP in order to access NHS Talking Therapies Hampshire.

To access our services please fill out your details below. If you have any questions or need help please call us on 02380 383920 and our team will be happy to assist you. You can also email us on info@italk.org.uk.

Part One: Self Referral Form

Part One: Referral Form › Review & Submit ›

Your consent

I am aged 16 or over.

I am currently, or have been in the last 12 months, under the care of a secondary mental health service (such as a Community Mental Health Team or Acute Mental Health Team).

I am currently receiving talking therapy from another service (such as counselling).

I have read and understood the privacy notice.

Your details

Please note that mandatory fields are marked with an asterisk (*).

As an NHS Service we need to record your 10 Digit NHS Number. Please check for your NHS Number on the NHS website: www.nhs.uk/nhs-services/online-services/find-nhs-number/

Your 10 Digit NHS Number

*Title

*DOB

*Gender

Pronouns

Other

*First Name

*Surname

*Address line 1

Address line 2

Town/City

County

*Postcode

*Home telephone number

Can we leave a voicemail?

*Mobile telephone number

Can we leave a voicemail?

Can we leave a text message?

If you do not have a Home or Mobile number, please enter 'N/A' in the relevant field. Please note that we need at least one form of contact to carry out Telephone Assessments.

When would you be available to take a call from NHS Talking Therapies Hampshire? Please indicate any preferred days/times in the box below.

We will do our best to contact you on your preferred day/time however this cannot be guaranteed. Our phone line is open 9am–6pm (Monday to Thursday) and 9am–4:30pm (Friday). Staff are available 8am–8pm (Monday to Thursday) and 8am–4:30pm (Friday).

*Email Address

*Permission to contact by Email?

(Please note: If you do not provide consent you will not be sent a confirmation email or booking reminders for any contact with NHS Talking Therapies Hampshire)

Next of kin details

Please provide us with your next of kin details. This provides the team involved in your care with useful and up-to-date information should there be an emergency. You can decline to give us next of kin details if you wish and this will not affect your treatment with us.

Next of Kin Name

Relationship to you

Telephone number

OR Do you wish to decline to provide information of next of kin?

Your Personal Information

Nationality

Ethnicity

Religious Belief or Affiliation

Language

Are you able to communicate in English?

Relationship Status

Sexuality

Disability

Are you currently in education?

NHS Talking Therapies Hampshire Health

NHS Talking Therapies Hampshire Health is our treatment pathway for people with a long-term physical health condition. Our NHS Talking Therapies Hampshire Health treatment options explore the mind-body link, and aim to equip you with tools to build your resilience and live well with a long-term physical health condition.

*Do you have a long-term physical health condition?

Is the impact of your long-term condition on your mental health part of your reason for referring?

It can be helpful for us to work together with your physical health teams. Are you happy for us to keep them updated about your care?

If yes, please provide contact details for your physical health team(s) Characters Remaining: 500

Armed forces

Are you an ex-serving member of the British Armed Forces?

Service Number

Length of Service (Years)

Length of Service (Months)

Discharge Date

Rank at Discharge

Mode of Discharge

Details of any operational tours Characters Remaining: 500

Are you directly dependent on an ex-serving member of the British Armed Forces?

Your GP surgery details

NHS Talking Therapies Hampshire is the local talking therapy service for Hampshire. If your GP surgery is not listed below, we are not able to accept your referral. Instead, search "IAPT" at www.NHS.uk to find your local talking therapy service.

*GP Surgery

GP Name

GP Address

If you do not know the name of your GP, please put 'Unknown' under 'GP Name'.

*Do you consent for your GP to be notified of your self-referral to NHS Talking Therapies Hampshire?

We can still offer you an appointment without your consent to share with your GP. However your practitioner will discuss our policy about GP consent with you. If you have any questions about this please call us on 02380 383920.

Perinatal

Are you pregnant?

Are you a parent to a baby under 1 year old?

*How did you hear about NHS Talking Therapies Hampshire?

About your mental health

*Have you ever had a mental health diagnosis? For example, bi-polar, personality disorder, schizophrenia

*From the following list, which best describes the reason for your referral?

If 'other', please describe the reasons for your referral (e.g. post-traumatic stress disorder (PTSD), obsessive compulsive disorder (OCD), social anxiety, social phobia, health anxiety) Characters Remaining: 500

At NHS Talking Therapies Hampshire we specialise in supporting people with symptoms of anxiety, depression, PTSD, OCD and phobias as their main problem. However, if you’ve been diagnosed with another mental health condition, or your main problem is something different such as addiction or disordered eating, we may link you with another trusted service.

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Recite - Accessibility and Language Options