Tower Hamlets Professional referral form TH Professional Referral Fom Referrer details Name of referrer Profession/Role Professional email address Organisation Address Organisation address line 1 Organisation address line 2 City/Town Postcode Telephone number Client details NHS Number (If known): RIO number (if known) Title First Name Surname Date of birth Gender Male Female Not Specified Prefer not to say Other Ethnic origin English/Welsh/Scottish/Northern Irish/British Irish Gypsy or Irish Traveller White and Black Caribbean White and Black African Indian Pakistani Bangladeshi Chinese African Caribbean Arab Other Interpreter required? Yes No If yes, which language? Address Client address line 1 Client address line 2 City/Town Postcode Mobile phone number Telephone number Email address Consent to contact via Phone Email Post Voicemail Text All of the above Emergency contact (Your emergency contact will only be contacted when we have concerns in order to help you find the correct immediate support) Full name Contact number Patient GP details GP Practice Name of GP Referral information Identified mental health problem (where possible, please include history of patients difficulties, duration and diagnosis) What does the patient hope to get out of a referral to Talking Therapies? (eg. Patient goals for therapy - feeling less depressed, reduce anxiety) Are there any immediate concerns about risk to self or others which requires urgent attention? If yes do no proceed with this referral, refer to NHS 111. Yes No Please can you describe any other concerns in regards to risk to self or to/from others that we should be aware of? Are there any concerns around alcohol or substance misuse? If yes please provide more information Is your client currently under the care of other professionals or specialists team for psychological or physical problems? If yes which team Is there any further relevant/important information that you think would be helpful for us to know?