/ 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:

  • Better understand your current problem and what is maintaining it.
  • Explore how what you think and what you do interact 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:

  • Workshops and courses
  • Self-help with printed material or online
  • Individual telephone or face to face sessions

The next step : Complete the form below and post, email or fax it to:
The Psychological Wellbeing Service (IAPT) SPA,Grebe House, Gloucester Centre, Morpeth Close,
Orton Longueville, Peterborough. PE2 7JU

Email: Fax:0845 045 0121

or complete a self referral onlineat

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 this form to us, please post it 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) / Title
Family Name / Gender
Date of Birth / Ethnicity
NHS number / Marital Status
Address
Email Address
Contact number / Mobile: Landline:
Can messages be left / Mobile: YES/NO Landline YES/NO
Your GP’s name
Surgery Name & Address
Is your GP aware of this referral? / YES/NO / If no, may we advise your GP of this referral? YES/NO
Do you consent to your medical records being viewed by us? / YES / NO
Nationality?
Do you need an interpreter? / YES/NO / If yes, please state language required:
Are you a UK Armed Forces Veteran or currently serving? / Veteran: YES/NO Currently serving: YES/NO
Name / Date of birth / Today’s date
Are you pregnant or have you given birth within the past year?
Are you a health care worker? / YES/NOgive 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 TWOPAGES AND SEND THEM WITH YOUR REFERRAL
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 / Don’t know
Are you suitable for or do you feel you would benefit from receiving employment support? / Yes / 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
(0) / Several days
(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
(0) / Several days
(1) / More than half the days
(2) / Nearly every day
(3)
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)

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
012345678
Not at all affected Very severely affected
Home management :
cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc.
012345678
Not at all affected Very severely affected
Social Leisure Activities:
with other people- e.g. parties, pubs, outings, entertaining etc.
012345678
Not at all affected Very severely affected
Private leisure Activities:
done alone e.g. reading,gardening,sewing, hobbies, walking etc.
012345678
Not at all affected Very severely affected
Family & Relationships :
form & maintain close relationships with others including the people that I live with
012345678
Not at all affected Very severely 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
012345678
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)
012345678
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)
012345678
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 we require more information, a member of our team may contact you to discuss your referral.

The information on this referral form remains in your ownership. Should we refer you to another agency, it may save you from having to complete another application form if we can share your information with them. Please indicate with a tick if you agree to this.

If my referral is forwarded to another agency, I give permission for my information to be shared with them.

Important note: We are not an emergency service and we are unable to provide help should you require immediate support in a crisis situation. If you require urgent support, please contact your GP as soon as possible. You may also contact the following:

The Samaritans: 116123 Urgent Care Cambridgeshire: 111

Lifeline: 08088 082121 (7pm -11pm 365 days a year)Your local Emergency Department / A&E

Private & Confidential / Page 1 / Version 431/12/2015