Online Self Referral Form

If you are experiencing difficulties such as anxiety or depression that are not going away, we may be able to help you.

Talking Change is an NHS service offering talking therapies and self-help programmes for people with anxiety and depression. Different treatments and therapies are recommended for different problems and we want to ensure that we offer you the right kind of therapy for your problem. Each element of this form helps us to initially assess your difficulties and enables us to advise whether a different service or approach may be more suitable. Please answer all the questions as best you can even if some questions may not seem to apply to your situation. It may take you up to twenty minutes to complete the form.

On receipt of your completed form, three team members will review the information you have provided and will recommend the next best step - this may be an assessment within our service with the Self Management Team or the Therapy Team, or they may recommend a different service. This recommendation is based upon the information you provide, the current NICE (National Institute for Health and Clinical Excellence) guidance that identifies the most appropriate treatment for your problem and the local services available to you.

We understand that when people experience mental health problems and feel distressed, it can become more difficult to concentrate and complete questionnaires. If you have any difficulties completing this form or you would prefer to discuss your referral on the telephone, please contact us on 023 9289 2920 and a team member will call you back. You can also ask your GP or someone you trust for help to complete this form.

PERSONAL DETAILS

Title & Name:
Address:

Postcode:
Date of Birth:

CONTACT DETAILS

Mobile phone:
May we leave a message on this number?

Home phone:
May we leave a message on this number?

E-mail Address
GP Surgery
Name of GP you last saw

REASONS FOR THIS SELF-REFERRAL

Please describe your current difficulties. Please give details of your symptoms, when they began and how you are coping at the present time. Please tell us whether you are using any medication, alcohol or substances and if you are currently in contact with any other services for this problem.

Do you have any holidays or planned trips away from home in the next four weeks as we may try to contact you to discuss your self-referral? (Please give dates if so).

Please list any previous contact with other mental health professionals.

Do you have any special requirements to enable you to use this service? (e.g. an interpreter, disabled access).

GAD7

Over the last 2 weeks, how often have you been bothered by any of the following problems?
(Please tick one box for each question)

	Not at all	Several Days	More than half the days	Nearly every Day
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

PHOBIA SCALE

Choose a number from the scale below to show how much you would avoid each of the situations or objects listed. Write the number in the box opposite the situation.

1). I avoid social situations due to a fear of being embarrassed or making a fool of myself
0.	1.	2.	3.	4.	5.	6.	7.	8.
Not at all	Slightly avoid them		Definitely avoid them		Markedly avoid them		Always avoid them
2). I avoid certain situations because of a fear of having a panic attack or other distressing symptoms (such as loss of bladder control, vomiting or dizziness)
0.	1.	2.	3.	4.	5.	6.	7.	8.
Not at all	Slightly avoid them		Definitely avoid them		Markedly avoid them		Always avoid them
3). I avoid certain situations because of a fear of particular objects or activities (such as animals, heights, seeing blood, being in confined spaces, driving or flying).
0.	1.	2.	3.	4.	5.	6.	7.	8.
Not at all	Slightly avoid them		Definitely avoid them		Markedly avoid them		Always avoid them

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 on the scale provided how much your problem impairs your ability to carry out the activity.

1. Work - If you are retired or choose not to have a job for reasons unrelated to your problem, please tick here Your ability to work is affected by your problems, please tick below.
0.	1.	2.	3.	4.	5.	6.	7.	8.
Not at all	Slightly		Definitely		Markedly		Severely
2. Home Management - Please rate how much your ability to do things around the house is impaired, e.g. cleaning, tidying, shopping, cooking, looking after home/children, paying bills etc.
0.	1.	2.	3.	4.	5.	6.	7.	8.
Not at all	Slightly		Definitely		Markedly		Severely
3. Social Leisure Activities - Please rate how much your social life has been affected, e.g. going to parties, pubs, outings, entertaining etc.
0.	1.	2.	3.	4.	5.	6.	7.	8.
Not at all	Slightly		Definitely		Markedly		Severely
4. Private Leisure Activities - Please rate how much your ability to do things on your own is affected, e.g. reading, gardening, sewing, hobbies, walking etc.
0.	1.	2.	3.	4.	5.	6.	7.	8.
Not at all	Slightly		Definitely		Markedly		Severely
5. Family and Relationships - Please rate how much your ability to form and maintain close relationships is affected, this includes the relationships with the people you live with.
0.	1.	2.	3.	4.	5.	6.	7.	8.
Not at all	Slightly		Definitely		Markedly		Severely

PHQ9

Over the last week, how often have you been bothered by any of the following problems?
(Please tick one box for each question)

	Not at all	Several Days	More than half the days	Nearly every Day
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

CORE-OM

Please read each of the 34 statements and think how often you felt this way over the last week. Then tick the box that is closest to this.

1. I have felt terribly alone and isolated

Not at all	Occasionally	Sometimes	Often	Most of the time
2. I have felt tense or nervous

Not at all	Occasionally	Sometimes	Often	Most of the time
3. I have felt I have someone to turn to for support when needed

Not at all	Occasionally	Sometimes	Often	Most of the time
4. I have felt OK about myself

Not at all	Occasionally	Sometimes	Often	Most of the time
5. I have felt totally lacking in energy and enthusiasm

Not at all	Occasionally	Sometimes	Often	Most of the time
6. I have been physically violent to others

Not at all	Occasionally	Sometimes	Often	Most of the time
7. I have felt able to cope when things go wrong

Not at all	Occasionally	Sometimes	Often	Most of the time
8. I have felt troubled by aches, pains or other physical problems

Not at all	Occasionally	Sometimes	Often	Most of the time
9. I have thought of hurting myself

Not at all	Occasionally	Sometimes	Often	Most of the time
10. Talking to people has felt too much for me

Not at all	Occasionally	Sometimes	Often	Most of the time
11. Tension and anxiety have prevented me from doing important things

Not at all	Occasionally	Sometimes	Often	Most of the time
12. I have been happy with the things I have done

Not at all	Occasionally	Sometimes	Often	Most of the time
13. I have been disturbed by unwanted thoughts and feelings

Not at all	Occasionally	Sometimes	Often	Most of the time
14. I have felt like crying

Not at all	Occasionally	Sometimes	Often	Most of the time
15. I have felt panic or terror

Not at all	Occasionally	Sometimes	Often	Most of the time
16. I made plans to end my life

Not at all	Occasionally	Sometimes	Often	Most of the time
17. I have felt overwhelmed by my problems

Not at all	Occasionally	Sometimes	Often	Most of the time
18. I have had difficulty getting to sleep or staying asleep

Not at all	Occasionally	Sometimes	Often	Most of the time
19. I have felt warmth or affection for someone

Not at all	Occasionally	Sometimes	Often	Most of the time
20. My problems have been impossible to put to one side

Not at all	Occasionally	Sometimes	Often	Most of the time
21. I have been able to do most things I needed to

Not at all	Occasionally	Sometimes	Often	Most of the time
22. I have threatened or intimidated another person

Not at all	Occasionally	Sometimes	Often	Most of the time
23. I have felt despairing or hopeless

Not at all	Occasionally	Sometimes	Often	Most of the time
24. I have thought it would be better if I were dead

Not at all	Occasionally	Sometimes	Often	Most of the time
25. I have felt criticised by other people

Not at all	Occasionally	Sometimes	Often	Most of the time
26. I have thought I have no friends

Not at all	Occasionally	Sometimes	Often	Most of the time
27. I have felt unhappy

Not at all	Occasionally	Sometimes	Often	Most of the time
28. Unwanted images or memories have been distressing me

Not at all	Occasionally	Sometimes	Often	Most of the time
29. I have been irritable when with other people

Not at all	Occasionally	Sometimes	Often	Most of the time
30. I have thought I am to blame for my problems and difficulties

Not at all	Occasionally	Sometimes	Often	Most of the time
31. I have felt optimistic about my future

Not at all	Occasionally	Sometimes	Often	Most of the time
32. I have achieved the things I wanted to

Not at all	Occasionally	Sometimes	Often	Most of the time
33. I have felt humiliated or shamed by other people

Not at all	Occasionally	Sometimes	Often	Most of the time
34. I have hurt myself physically or taken dangerous risks with my health

Not at all	Occasionally	Sometimes	Often	Most of the time

A Little Bit About You

We collect information about all the people who refer themselves to our service in line with Department of Health requirements and the Solent NHS Trust policy for equality and access. Within Talking Change we use the information to improve our provision of services to all members of the Portsmouth population. Some of the information is submitted to the Department of Health for analysis at a national level.

If you DO NOT want your personal information to be submitted to the Department of Health for inclusion in national statistics please select here.
Your treatment WILL NOT be affected by this decision.

1. Please tick the appropriate box to indicate your gender and living arrangements

Male	Female	Transgender	Rather not say
Living Alone	Living with others

2. Occupation: Please tick one

Employed Full Time
Employed Part-Time
Unemployed on Job Seekers Allowance
Long term disability claiming Incapacity Benefit, Income Support or both; or Employment and Support Allowance
Homemaker, looking after your home and/or family and not employed
Unemployed and not receiving benefits
Unpaid voluntary work - receiving benefits
Retired from work, not on work related benefits
Education with or without part-time work

3. Employment and training support

We have Employment Advisors who are part of our team. They may be able to help you look for work or training, or help with applications or interviews. They can also help you negotiate your return to work with your employer.

Would you be interested in speaking with one of our Employment Advisors?

4. Where did you first hear about our service?

5. British Armed Forces - are you

Currently serving in the Armed Forces?
Ex-Armed Forces personnel?
A dependent of a serving member of the Armed Forces?
A dependent of ex-serving member of Armed Forces?
None of the above?
Unsure

6. Are you or your partner currently pregnant or had a baby in the last 12 months?

Yes No Rather not say

7) Disability

Under the Disability Discrimination Act 1995, a disabled person is described as anyone with "a physical or mental impairment which has a substantial and long term adverse effect on his or her ability to carry out normal day to day activities".

Do you consider yourself to have any of the following disabilities?
	Yes	No	Rather not say
Behaviour and emotional
Speech
Hearing
Manual dexterity
Memory of ability to concentrate, learn or understand
Mobility and Gross Motor
Perception of physical danger
Personal self-care and continence
Progressive conditions e.g. Multiple Sclerosis, Motor Neurone Disease, HIV
Sight
Other (please describe)

8. Long term health conditions

Do you consider yourself to have a long term health condition?

Yes No Rather not say

9. Sexual orientation

We believe that it is helpful to gather this information for the purpose of determining equality of access. Although analysis will be more effective if everyone provides a response, we appreciate that this is a sensitive and personal question. Please be aware that your response is voluntary.

Heterosexual No Bisexual Not sure Rather not say

10. Ethnic Origin: Please tick the appropriate category

British	Bangladeshi
Irish	Any other Asian Background
Any Other White Background	Caribbean
White and Black Caribbean	African
White and Black African	Any Other Black Background
White and Asian	Chinese
Any Other Mixed Background	Any Other Ethnic Group
Indian	Rather Not Say
Pakistani

11. Religion or belief

What is your religion/belief?

Please state if you have none or would rather not say

Date form completed

When we receive your information we will contact your GP to let him/her know that you have referred yourself to the service, and to request any further information that would be helpful to us.

A team member will aim to contact you within two weeks of receiving your information to explore the best way forward for you. Please make sure that you complete your contact details in full to help us with this process.

Talking Change
Psychological Services
First Floor, 8F The Pompey Centre
Fratton Way
Portsmouth
PO4 8TA

If you have any problems filling in the forms please contact us on:-
Telephone: 02392 892920
Fax: 02392 892947