Please use this form to make a clinical referral for Well Action group or individual therapy.
Self-referrals are accepted along with referrals from GP practices and NHS secondary care services.
Please fill in all the fields.
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Client Name:
Preferred Name:
Client's preferred pronouns: Select option He/Him She/Her They/Them Xe/Xir Ze/Zir Prefer not to say Unknown
Client date of birth: Select month January February March April May June July August September October November December
Group therapy? Individual therapy?
Client contact:
Client NHS Number:
Client town of residence:
Client's GP practice:
Client's GP name:
Next of kin name:
Next of kin emergency contact:
What does the client need help with:
Disabilities or longterm health conditions that might impact ability to access a consulting room or make use of a physical therapy:
Health risks? E.g. serious allergies, heart failure, epilepsy etc.:
Previous contact with mental health services (NHS or Private):
If any previous contact, was the outcome positive, indifferent or negative? Select option Positive Indifferent Negative
Does the client use any non-prescription drugs or have any addictions (including alcohol or tobacco). If so please specify:
Please list any prescribed medications taken regularly:
Please list any psychiatric diagnoses:
Please list any other risk factors (suicidality, self-harm, forensic etc.):
Please describe any history of significant trauma:
