Military Veterans’ Service

Referral Form

We offer specialist psychological interventions to military veterans of the British Armed Forces for their service-related difficulties. Full referral criteria can be found on the last page of this form.If you are unsure about the appropriateness of your referral please contact our Duty Team on 0161 253 6638(0830-1700 Monday to Friday).

Please note all fields are mandatory. Please ensure they are completed as this may delay the referral process.

Today’s Date: / Has the client consented to the referral Yes / No
Client Details / Referrer Details (If not GP)
Name: / Name:
DOB: / Department:
NHS No:
Ethnicity:
Gender: / Contact No:
Client Address
Please include full postal address / GP Details
GP Name:
GP Surgery:
GP Address:
Contact Details / Okay to contact? Yes/No
Home telephone:
Mobile telephone:
Service Related Information / Additional information
Service Number: / Are there any language / mobility / disability issues we should be aware of? / Yes / No
Branch of the Armed Forces / Army/RAF/RN/RM/Merchant Navy/TA/RN or RAF Reservist / If Yes, please expand:
Join Date: (Year Acceptable)
Leave Date: (Year Acceptable)
Deployed Operationally / Yes / No
Next of Kin Details
Where known
Name:
Relationship: / Contact Number:
Address:
Any Children under 18 years of age? / Yes/No
Childs Name / DOB / Parent/Guardian
Parent/Guardian Details:
Name: / Contact No:
Relationship to Client:
Address (if different from Client)
Any child protection or child in need issues or concerns? / Yes/No
If yes please, outline the steps you have taken to promote the safety of the child/children.
Reason for referral, presenting problems
If possible please include: the nature of the problem; triggers; time of onset and the clients view of what they want help with. Please describe why it is considered their needs are unable to be met via local services at this time.
Please include any previous relevant assessment information
[The service offers a range of psychological interventions such as: Cognitive Behavioural Therapy (CBT) including trauma-focused CBT, Eye Movement Desensitisation & Reprocessing (EMDR), Psychodynamic Psychotherapy, Clinical Psychology, in addition to some case management support for complex clients presenting with comorbid difficulties].
PHQ9 Score:
GAD 7 Score:
IES-R Score:
Current Alcohol or Illicit Substance Use
(Please consider referral to substance misuse services if this is the primary presentation. The MVS will offer support to Veterans with co-morbid substance use where there is an additional military related psychological problem)
Risk Issues(if so provide as much detail as possible)
Previous Mental Health or Psychological Input?
Current Medication
Are there any other professionals involved?
e.g. Social Worker, Probation Officer. / YES / NO
If yes please give details below:
Name / Designation / Contact No
Referral criteria
Veteransmust meetthefollowingcriteriainorder toaccesstheservice:
1.TheymustbeaveteranoftheBritish ArmedForces (includescurrentreservists when not mobilised).
2.Theirmentalhealthconditionmustberelatedtotheirmilitaryservice,suchaslinked to experiences
whilstserving and/ordifficultieswith transition tocivilianlife.
3.Theindividualmustbesuitableforpsychological therapybutunableorunwilling to access local mainstream
services.
4.TheMilitaryVeterans’Servicedoesacceptreferralsfor veterans whosementalhealth problems are
co-morbidwith alcohol/substancemisuse,andthosewithsignificantforensic histories.
5.Theservicedoesnotacceptreferralsfor veterans under thecare ofsecondarycare mental health or
specialistservices, unlesstheveteranis stableenoughfordischarge to theMilitaryVeterans’Service.
THIS REFERRAL WILL BE SCREENED BY OUR SERVICE AND YOU WILL BE NOTIFIED BY LETTER OF THE OUTCOME
PLEASE CONTACT THE SERVICE ON 0161 253 6638 IF ANY FURTHER ADVICE IS REQUIRED
FAX NO. 0161 761 7083
Military Veterans Service
2Floor, Humphrey House
Angouleme Way
Bury
BL9 0BT
Email:
Veterans canself-refer bycalling0300323 07078or completingthesecureonlineformat:

1