PRIMARY CARE MENTAL HEALTH TEAM
Central and North West London NHS Foundation Trust, Central London Community Healthcare NHS Trust and Depression
Alliance working together.
Central and North West London
Central London Community Healthcare
NHS Foundation Trust
NHS Trust
GP Referral Form
The patient will be contacted within 3 working days by telephone to enable assessment for the most suitable treatment.
Fields marked * are mandatory.
PATIENT
GP REFERRER
Forename*
Date of Referral*
Surname*
Name
Address*
Address*
Telephone*
Telephone
Can a message be left at this number? Yes
No
Fax
DoB*
E-mail
NHS Number*
Signature
Gender
Interpreter Required
Yes
No
Ethnicity
Language
REASONS FOR REFERRAL
EU32 Depression
EU401 Social Phobia
EU411 Generalised Anxiety
EU42 Obsessive Compulsive Disorder
EU412 Mixed Anxiety and Depression
EU431 Post Traumatic Stress Disorder
EU410 Panic Disorder
EU50 Eating Disorder (mild)
EU40 Specific Phobia
EU432 Adjustment Disorder
EU413 Other Health Anxiety
Known Severe Mental Illness (not a first episode)
FURTHER INFORMATION*:
Please describe the difficulties the patient is experiencing in as much detail as possible, including symptoms and impact on
day to day life.
KEY CLINICAL INFORMATION
Does the patient have a current risk or a history of suicide
attempts, self-harm, or harm to others?
Is the patient receiving any medication for mental health?
Any mental health or relevant medical history? (e.g.
previous contact with mental health services)
Does the patient have any legal, housing, educational,
work, financial needs or special needs such as mobility or
hearing impairment disability?
Additional Details
Yes
No
Yes
No
Yes
No
Yes
No
DOES YOUR PATIENT HAVE A PREFERENCE FOR ANY OF THE FOLLOWING INTERVENTIONS?
No preference: please assess for suitable psychological
Guided Self Help
Counselling
Cognitive Behavioural Therapy
CPN Liaison Team
intervention
Depression Alliance provides a local service of self-help groups and social events. Tick if your patient would like
to be contacted by them.
Please e-mail this form to your hub:
North Hub
Email: adminnorthhub@nhs.net
St Charles’ Hospital, Exmoor Street
London W10 6DZ. Tel: 020 8962 4748
South Hub
Email: adminsouthhub@nhs.net
15 Gertrude Street, London
SW10 0JN
Tel: 020 7349 2400
PLEASE COMPLETE THE PHQ-9 AND GAD-7 SCORES ON THE NEXT PAGE
Patient Name:
DoB:
PHQ9
Over the last two weeks how often have you been bothered
by the following problems?
A
Little interest or pleasure in doing things
B
Feeling down, depressed, or hopeless
C
Trouble falling or staying asleep, sleeping too much
D
Feeling tired or having little energy
E
Poor appetite or overeating
F
Feeling bad about yourself – or that you are a failure
or have let yourself or your family down
G
Trouble concentrating on things, such as reading the
newspaper or watching television
H
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
I
Thoughts that you would be better off dead or of
hurting yourself in some way
Severity
Score
Mild depression
Moderate depression
Severe depression
=
=
=
5 – 10
10 – 18
19 – 27
If you checked off any problems, how difficult have
these problems made it for you to do your work, take
care of things at home or get along with other people?
GAD7
Over the last two weeks how often have you been bothered
by the following problems?
Date of Referral:
0
Not at all
1
Several
Days
2
More than
half the days
3
Nearly
every day
Total Score:
Not difficult
at all
Somewhat
difficult
0
1
Several
Days
Not at all
Very difficult
Extremely
difficult
2
Over than half
the days
3
Nearly
every day
Feeling nervous, anxious, or on edge
Not being able to stop or control worrying
Worrying too much about different things
Trouble relaxing
Being so restless that it’s hard to sit still
Becoming easily annoyed or irritable
Feeling afraid as if something awful might happen
Total Score (add your column scores)
If you checked off any problems, how difficult have these
problems made it for you to do your work, take care of things at
home, or get along with other people?
Not difficult
Somewhat
at all
difficult
Very difficult
Extremely
difficult
KCPCTITAF2011