referral form - Warrington Primary Care Psychological Service

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referral form - Warrington Primary Care Psychological Service
WARRINGTON PRIMARY CARE PSYCHOLOGICAL SERVICE WEBSITE REFERRAL FORM
Date:
PERSONAL DETAILS:
Mr
Mrs
Ms
GP DETAILS:
Miss
Other
Name:
Surname:
Practice Address:
Forename:
DOB:
Age:
Address:
Telephone:
Do you consent for us to communicate with your GP?
yes
no
INVOLVEMENT WITH MENTAL HEALTH SERVICES
Post Code:
Tel landline:
Are you currently involved with any mental health
services?
Mobile:
Can we leave a message - please tick
yes
Landline yes
no
Mobile yes
no
no
If yes, please give details.
Ethnicity:
White British
White Irish
White& Black Caribbean
White & Black African
White & Asian
Asian or Asian British Indian
Asian or Asian British Pakistan
Asian or Asian British Bangladeshi
Black or Black
British Caribbean
Black or Black British African
Chinese
Other, please state:
MEDICATION
Are you currently taking any prescribed medication?
yes
no
Please give details (E.g. drug, dose, date commenced).
Have you previously been involved with any mental
health services?
yes
no
If yes, please give details.
REASON FOR REFERRAL
Please give brief details of the problem you are currently experiencing (E.g. how long it has lasted for, symptoms you
experience and how it is impacting on work, family and social life).
Have you ever or are you currently serving in the Armed Forces?
yes
no
Are you currently pregnant or in the post-natal period (up to 1 year following birth)?
yes
no
FOR OFFICE USE ONLY:
MEASUREMENT TOOLS: GAD-7 Score
PHQ-9 Score
Our Postal Address: WPCPS, Ribban Court, 20 Dallam Lane, Warrington, WA2 7NG
Tel: 01925 401720
Fax: 01925 401 729
Once you have returned your referral, please allow at least 48 hours for the referral to be
processed. You will then need to activate your referral by calling the service within
14 days.

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