Mental Health Direct 24 hour contact number 0300 555 1000

Redbridge IAPT Service

Goodmayes Hospital

Barley Lane

Goodmayes

Ilford Essex IG3 8XJ

Tel: 0300 555 1220

Fax: 0844 493 0233

Referral to Redbridge IAPT Service

If you would like to refer yourself to the Redbridge IAPT service, please read and complete all questions on the following pages and return to us at the above address or fax number.

Once we receive your forms if we feel you are suitable for treatment within our service,a member of our team will be in touch with you to offer you an assessment appointment.

If we feel you are not suitable for our service a clinician will inform you and your GP of possible options that you can then discuss with your GP for referral.

Redbridge IAPT

IAPT – STEP 3 REFERRAL FORM

Please complete ALL questions on this form.

Please give a brief explanation of your current difficulties, symptoms you may be having, and how long you have been experiencing this………………………………………………………………………………………
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Have you had any therapy before? / YES / NO
If YES, please explain……......
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Have you ever had any other previous mental health help / support? / YES / NO
If YES, please explain……......
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Are you currently taking any medication related to your mental health? / YES / NO
If YES, what do you take and what dosage?......
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Do you have a history of alcohol or drug use? / YES / NO
If YES, please explain......
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Please complete ALL questions on this form.

Mr / Mrs / Miss / Other : / Full Name:
Male / Female / DOB:
Full Address:………………………………….……………………………………………………………..
…………………………………………………………………………….Post Code…………………………..
Home Phone :…………………………………………….
Can we leave a voicemail? YES / NO / Mobile Phone :………………………………………..
Can we leave a voicemail / text? YES / NO
Email Address :…………………………………………………………………………………………………………
Are you happy to be contacted via email? YES / NO
Marital Status:
 Married / Civil Partner Divorced / Civil Partnership Dissolved  Single
 Separated  Widowed / Civil Partnership Survivor
Accommodation Status:
 Council Tenant Owner Occupier
 Private Rented Live with Family/Friends  Other – please specify :
Ex British Armed Forces : Yes NoDependent of ex-serving member
Ethnic Origin:
White BritishWhite IrishWhite OtherChinese
Mixed White/Black CaribbeanMixed White/Black AfricanMixed White/AsianMixed Other
Asian/British IndianAsian/British PakistaniAsian/British BangladeshiAsian/British Other
Black/British CaribbeanBlack/British AfricanBlack/British Other
Any Other - please specify:
Nationality:
If you are an overseas visitor, are you able to provide proof that you have resided in the coutry for more than 1 year? YES / NO / Religion :
Interpreter : YES / NO / Language :
Do you have any disabilities: / YES/NO
If YES, please state………………………...………………………………..
Do you have any long Term Health Conditions: / YES/NO
If YES, please state…………………………………………………………..
 Unemployed  Employed – Please state job title / type of employment :
Sexual Orientation :HeterosexualHomosexual Bisexual
GP Name and Address :

Information Sharing:

Please read the enclosed leaflet titled “Use of patient information by this service”. Please note we normally share limited information with colleagues such as your GP in order to enhance your care and benefit you. If you have any concerns about what information will be shared, please discuss with your therapist.

If we think that your needs will be better met by a different NHS service, we would like to forward your completed forms and questionnaires to them. This will help them process your referral without having to ask you the same questions again. If you DO NOT want us to do this, please let us know.

You have the right to receive copies of correspondence about your care sent between health practitioners. Would you like to receive copies of any correspondence we send to your GP of other healthcare providers?

Yes No 

If YES, can these be sent to your home address?

Yes No 

I consent to use of my information as described in “Use of patient information by this service”

Name:………………………………………………………

Signed:……………………………………………………..

Date:………………………………………………………..

SESSION NO : ……………….. (to be completed by clinician)

Please complete all questions on both sides

NAME : ………………………………………………………………DATE : ……………………………

Over the last 2 weeks how often have you been bothered by any of the following problems?

PHQ-9 / SCORE : / Not at all / Several days / More than half the days / Nearly every day
1. / Little interest or pleasure in doing things / 0 / 1 / 2 / 3
2. / Feeling down, depressed, or hopeless / 0 / 1 / 2 / 3
3. / Trouble falling or staying asleep, or sleeping too much / 0 / 1 / 2 / 3
4. / Feeling tired or having little energy / 0 / 1 / 2 / 3
5. / Poor appetite or overeating / 0 / 1 / 2 / 3
6. / Feeling bad about yourself – or that you are a failure, or have let yourself of your family down / 0 / 1 / 2 / 3
7. / Trouble concentrating on things, such as reading the newspaper or watching television / 0 / 1 / 2 / 3
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 / 0 / 1 / 2 / 3
9. / Thoughts that you would be better off dead or of hurting yourself in some way / 0 / 1 / 2 / 3
GAD-7 / SCORE : / Not at all / Several days / More than half the days / Nearly every day
1. / Feeling nervous, anxious or on edge / 0 / 1 / 2 / 3
2. / Not being able to stop or control worrying / 0 / 1 / 2 / 3
3. / Worrying too much about different things / 0 / 1 / 2 / 3
4. / Trouble relaxing / 0 / 1 / 2 / 3
5. / Being so restless that it is hard to sit still / 0 / 1 / 2 / 3
6. / Becoming easily annoyed or irritable / 0 / 1 / 2 / 3
7. / Feeling afraid as if something awful might happen / 0 / 1 / 2 / 3
IAPT Phobia Scales
Choose a number from the ones below to show how much you would avoid each of the situations or objects listed below.
0 1 2 3 4 5 6 7 8
would not slightly definitely markedly always
avoid it avoid it avoid it avoid it avoid it
1. / Social situations due to a fear of being embarrassed or making a fool of myself
2. / Certain situations because of a fear of having a panic attack or other distressing symptom (such as loss of bladder control, vomiting or dizziness)
3. / Certain situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in confined spaces, driving or flying)
IAPT Employment Status
Please tick which, if any, of the following best describes your current status :
Employed : FULL TIME
Employed : PART TIME
Employed : SELF EMPLOYED
Unemployed
Unemployed : SEEKING WORK
Benefits
Student : FULL TIME
Student : PART TIME
Homemaker
Volunteer
Retired
Are you receiving Statutory Sick Pay? / Yes / No
Are you suitable for or feel you could benefit from employment support ? / Yes / No
Work and Social Adjustment
People’s problems sometimes affect their ability to do certain day to day tasks in their lives. To rate your problems, look at each section and determine from the scale below how much your problem impairs your ability to carry out this activity.
0 1 2 3 4 5 6 7 8
Not at all slightly definitely markedly very severely
1. / WORK : If you are retired or choose not to have a job for reasons unrelated to your problem, please write ‘N/A’ - not applicable
2. / HOME MANAGEMENT : Cleaning, tidying, shopping, cooking, looking after home / children, paying bills, etc.
3. / SOCIAL LEISURE ACTIVITIES : With other people, e.g. parties, pubs, outings, entertaining, etc.
4. / PRIVATE LEISURE ACTIVITIES : Done alone, e.g. reading, gardening, sewing, hobbies, walking, etc.
5. / FAMILY AND RELATIONSHIPS : Form and maintain close relationships with others including the people that I live with.
Psychometrics : Medication
Are you taking any form of medication for any Mental Health condition? / Yes / No