Referral for an Adult (yourself or someone else aged 18 or over)

Thank you for considering making a referral to Psychological Pathways. We appreciate it can be difficult for people to find the right service when they are in need. Our service is designed to support clients with mild-moderate emotional health and wellbeing needs eg anxiety, low mood etc and where a short-term intervention can be helpful.

We appreciate that you and/or your family may be experiencing difficult challenges at this time but it is important for you to understand that we do not automatically accept all referrals we receive. We reserve the right for appropriate clinical decision making as to whether we are able to provide the correct intervention and support for you and/or your family. Please see our ‘Frequently Asked Questions’ (FAQs) document for more information.

Adult

If you are making a referral for someone else (over 18) we need some information about you
Are you the next of kin (if not please provide next of kin details below)
Details of the person requiring support:
Can we leave a message?(Required)
Can we sent a text?(Required)
DD slash MM slash YYYY
Gender(Required)
Next of Kin Details (if not already provided)

Next of kin will only be contacted in case of an emergency

Reason for Referral

Please describe some of the concerns that have led you to seek support now. Please see our FAQs for details on what is/is not considered an appropriate referral for our service.

Additional Information:

Are you currently receiving support from any NHS mental health services or private therapists (including, adult mental health, counselling, psychological services, psychiatry, addiction services etc)

Are you currently receiving support from any NHS mental health services or private therapists (including, adult mental health, counselling, psychological services, psychiatry, addiction services etc)

If yes, please give brief details of the service(s) you are currently receiving support from and the nature of the difficulties being experienced.

In the past have you previously accessed any NHS mental health services or private therapists (including, adult mental health, counselling, psychological services, psychiatry, addiction services etc)

In the past have you previously accessed any NHS mental health services or private therapists (including, adult mental health, counselling, psychological services, psychiatry, addiction services etc)

If yes, please provide brief details of when this was, the type of service used and the nature of the difficulties at that time.

Your current emotional wellbeing:

Do you currently have any concerns about your ability to keep yourself safe e.g. thoughts or plans of suicide or self harm?

Do you currently have any concerns about your ability to keep yourself safe e.g. thoughts or plans of suicide or self harm?

Do you, or someone in your family, think alcohol is a significant problem for you?

Do you, or someone in your family, think alcohol is a significant problem for you?

Are you currently using recreational drugs or misusing any prescription medication?

Are you currently using recreational drugs or misusing any prescription medication?

If you have any concerns about safety (your own or others) please contact your GP, Out of Hours GP, Lifeline NI (24/7) crisis helpline, 0808 808 8000 (deaf and hard of hearing Textphone users can call Lifeline on 18001 0808 808 8000).

Payment

How do you wish to pay:

How do you wish to pay:

If you have private health insurance please provide the following information. We will not be able to progress with your referral until this information is provided:

*Please note, our practice is not registered with all UK wide PHI providers but we will advise you if this affects your referral before proceeding.

Consent

I consent to the information in this form being used for the purposes of clinical decision making regarding suitability for this service.

I confirm that the person I am referring is aware that this referral is being made and I have their permission to provide information about them (including about their health) for the purposes of determining their suitability for this service.

GDPR

We will not share your information with anyone outside our practice, unless we believe you, or someone else is at imminent risk of harm. In this instance we are legally bound to share information in order to keep you or others safe.

I hereby agree that the data entered in this referral form will be stored electronically and will be processed and used for the purpose of establishing contact. I am aware that I can revoke my consent at any time.

I confirm I have read and agree to the above statements regarding consent and GDPR

Psychological Pathways does not automatically accept all referrals received and reserves the right for appropriate decision making with respect to the criteria detailed in the FAQs as to what is/is not considered to be an appropriate referral for our service.

If you have any concerns about safety (your own or others) please contact your GP, Out of Hours GP, Lifeline NI (24/7) crisis helpline, 0808 808 8000 (deaf and hard of hearing Textphone users can call Lifeline on 18001 0808 808 8000).