TalkingSpace Referral
Form
(Completed by you or your GP)
Please return to:
TalkingSpace,
Oxbridge Court,
Osney Mead,
Oxford, OX2 0ES
(Postal address only)
Tel: 01865 325777
Fax: 01865 325778
Email: talkingspace@nhs.net
For office use only:
Group
Step 2 – workshop / Lupina / f2f / CBT-i
Step 3 – f2f / group /
Step 4
CONFIDENTIAL
NHS number if you know it
What is your date of
birth
Title (Mr, Mrs, Miss, Ms, Dr,
Rev)
What is your full name?
What is the name of your GP
surgery?
Who is your GP?
What is your address
Including your postcode?
Should we need to contact you by phone this would be within working hours, please let us know which number is best to you reach
you on during the day:
Home
Mobile
Work
Home telephone
can we leave a message on this number?
Yes
No
Work telephone
can we leave a message on this number?
Yes
No
Mobile telephone
can we leave a message on this number?
Yes
No
Email address
can we leave a message on this number?
Yes
No
We would like to keep your details on file to let you know about service developments and opportunities to be involved in
developing the service. If you would like to be involved and be a part of our People Involvement programme please tick
this box:
What would you describe your ethnicity as (please only tick one):
White British
White Irish
Any other White
Background
Mixed – White & Black
Mixed – White & Asian:
Any other mixed
African:
background:
Asian or Asian British –
Asian or Asian British –
Any other Asian
Pakistani
Bangladeshi:
background
Black or Black British –
Any other black
Chinese or other
African
background
ethnic Group
Mixed – White and
Caribbean
Asian or Asian British –
Indian
Black or Black British –
Caribbean
Any other ethnic group
Please tell us your nationality? ……………………………………………………
Marital Status:
Single
What language do you normally
speak?
Do you need an
Yes
interpreter?
What is your gender? Male
Married
Divorced
Widowed
Separated
other
No
Female
Not
specified
Do you provide regular care for another family member/friend/neighbour?
Are you a member of the Armed Forces or have been at any point?
Are you a relative or carer of someone who is or was in the armed forces?
Where did you hear about TalkingSpace: GP
Poster
Mind
Leaflet
Yes
Yes
Yes
no
No
No
Job Centre Plus
Other
………...
Please let us know if you have problems of?
Mental health problems due to use of alcohol
Depression on more than one occasion
Agoraphobia
Obsessive-compulsive disorder
Bereavement
Panic disorder
(Please tick at least one)
Bi-polar affective disorder
Depression on one occasion
Generalised anxiety
Mixed anxiety and depression
Social anxiety
Specific phobias e.g. needles
Post-traumatic stress disorder
Somatoform disorders
Eating Disorder
Mental health problems
Insomnia
Can you tell us more about any of these problems or ones that are not on this list, in the space below?
How do they affect you? E.g. your sleep, mood, ability to carry out day to day tasks, relationships with other people etc
When did they start? Have they happened in the past? Are you currently getting any treatment or have you had any previous
help?
Please can you give us details about your home and family life? It would be good to know if there are any particular problems.
What do you feel is the most difficult problem?
Do you have any physical health problems? Breathing problems
Do you have problems getting around? Yes
No
Diabetes
Heart problems
If yes, please tell us a here.
Are you currently having thoughts of suicide/harming yourself? Yes
If yes, please tell us more here.
Have you ever harmed yourself?
If yes, please tell us more here.
Yes
No
or hurting someone else? Yes
No
No
Do you need help completing this form?
Yes
No
If yes, then please give TalkingSpace a call.
If counselling is decided to be the best course of therapy for you we will need to pass your details to PML who provide
counselling in GP Practices across Oxfordshire or to the Isis Centre who provide medium term counselling in Oxford.
Signature ……………………………………………………
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Date: ……………………………….
3 of 4
A16 – Are you currently off of work on sick leave? Yes/No (Please circle)
4 of 4