Psychological Wellbeing Service (IAPT)
Single Point of Access
Self Referral Form
Who are we? The Psychological Wellbeing Service (IAPT) teams based in Peterborough, Fenland, Huntingdon and
Cambridge are there to help people manage common mental health problems such as anxiety and low mood which
can create difficulties in a person’s everyday life. We accept self referrals from people over the age of 17 and who
reside within Cambridgeshire or are registered at the Wansford and Kingscliffe Practice and Oundle Medical Practice.
We aim to help you to:
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

Better understand your current problem and what is maintaining it.
Explore how what you think and how you behave interacts with how you are feeling.
Agree what you want to improve and to develop new ways of thinking, behaving and feeling.
Agree goals to help improve your quality of life.
Help is offered in different ways:
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Workshops and courses
Self help with printed material or on line
Telephone or individual face to face sessions
The next step : Complete the form below and post, email or send it by fax to:
The Psychological Wellbeing Service (IAPT) SPA. Grebe House, Gloucester Centre, Morpeth Close,
Orton Longueville, Peterborough. PE2 7JU
Email: selfreferIAPT@cpft.nhs.uk Temporary Fax: 0845 045 0121 or complete a self referral online at
www.cpft.nhs.uk
Please note that unless you are sending an email from an encrypted system, this method of communication may not
be secure. If you have any concerns about emailing it back to us, please post to the above address.
Self Referral line: 0300 300 0055 Mon – Fri, 9am – 5pm (if you would prefer to speak to us to make
your referral)
First Name(s)
Family Name
Date of Birth
NHS number
Address
Email Address
Contact number Mobile:
Can messages
Mobile:
be left
Your GP’s name
Surgery Name & Address
Title
Gender
Ethnicity
Marital Status
Landline:
Landline
YES/NO
YES/NO
Is your GP aware of this referral?
YES/NO
If no may we advise your GP of this referral?
Do you consent to your medical records being viewed YES / NO
Nationality?
Do you need an interpreter?
YES/NO If yes please state language
required:
Are you a UK Armed Forces
Veteran: YES/NO
Currently serving: YES/NO
Veteran or currently serving?
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YES/NO
Name
Date of birth
Are you pregnant or have you
given birth within the past year?
Are you a health care worker?
YES/NO give brief details
What is your main difficulty and how long has this been a problem?
Please specify
Have you received or are you currently receiving treatment for this problem?
YES / NO
If yes please give details
Have you ever had thoughts of or have you tried to harm yourself in any way?
YES / NO
If yes please give details
Do you have any issues with alcohol or recreational drugs?
Past YES / NO
Current YES / NO
If yes please give details
Are you currently taking any medication?
YES / NO
If yes please provide details
Do you have any ongoing or long term physical health problems e.g. asthma or diabetes?
YES / NO
If yes please provide details
Do you have any disability or mobility difficulties?
YES / NO
If yes please give details?
Please tell us about what you are hoping to gain from our service and what your goals are.
You can use a separate sheet if required
PLEASE COMPLETE THE QUESTIONNAIRES ON THE NEXT TWO PAGES AND SEND THEM WITH YOUR
REFERRAL
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Name
Date of birth
IAPT Employment Questionnaire
Please tick which of the following options best describes your status
Employed Full-Time
Unemployed (seeking work)
Student (full time)
Employed Part time
Unemployed
Student (part time)
Self Employed
Benefits
Homemaker
Retired
Volunteer
Are you currently receiving Statutory Sick Pay?
Yes
No
Are you suitable for or do you feel you would benefit from receiving employment support?
Yes
Don’t know
No
How did you find out about our Service?
PHQ-9 (Please tick the box next to each of your answers)
Over the last 2 weeks, how often have you been bothered by any of
the following problems:
Not at all
Several
days
(0)
(1)
More than
half the
days
(2)
Nearly
every day
(3)
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 other 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.
PHQ-9 Total Score (staff use)
GAD-7 (Please tick the box next to each of your answers)
Over the last 2 weeks, how often have you been bothered by any of
the following:
Not at all
Several
days
(0)
(1)
More than
half the
days
(2)
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
GAD-7 Total Score (staff use)
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Nearly
every day
(3)
Name
Date of birth
Work & Social Adjustment
Please look at the questions below and give a number between 0 and 8 to describe how much your problems affect
you in each area.
Work/ Education:
if you are retired or choose not to have a job for reasons unrelated to your problems please circle N/A
0
1
2
3
4
5
6
7
8
Not at all affected
Very severely affected
Home management :
cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc.
0
1
2
3
4
5
Not at all affected
6
7
Very severely affected
8
Social Leisure Activities:
with other people- e.g. parties, pubs, outings, entertaining etc.
0
1
2
3
4
Not at all affected
5
6
7
Very severely affected
8
5
6
7
Very severely affected
8
6
7
Very severely affected
8
Private leisure Activities:
done alone e.g. reading, gardening, sewing, hobbies, walking etc.
0
1
2
3
4
Not at all affected
Family & Relationships :
form & maintain close relationships with others including the people that I live with
0
1
2
3
4
5
Not at all affected
Total W&SAS Score (staff use)
IAPT Phobia
Please choose a number from the scale below to show how much you would avoid each of the situations for the
reasons given:
Social situations because I fear being embarrassed or making a fool out of myself
0
1
2
3
4
5
6
7
8
Would not avoid
Would always avoid
Certain situations because I fear having a panic attack or other distressing symptoms (such as loss of
bladder control, vomiting or dizziness)
0
1
2
3
4
5
6
7
8
Would not avoid
Would always avoid
Certain situations because I fear particular objects or activities (such as animals heights, seeing blood, being
in confined spaces, driving or flying)
0
1
2
3
4
5
6
7
8
Would not avoid
Would always avoid
Total Phobia Score (staff use)
Thank you for taking the time to complete the self-referral form and the questionnaires.
If required a member of our team may contact you to discuss your referral further. Please note that unless you are
sending the email from an encrypted system, this method of communication may not be secure. If you have any
concerns about emailing it back to us, please post to the above address.
Important note: We are not an emergency service and are unable to provide help should you require immediate
support in a crisis situation. If you do require more urgent support please discuss your referral with your GP as soon
as possible. You may also contact the following:
The Samaritans 08457 909090
Urgent Care Cambridgeshire dial 111
Lifeline 08088 082121 (7pm -11pm 365 days a year)
Your local Emergency Department / A&E
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