NHS Lanarkshire Referral - The Talking Rooms - Counselling & Psychotherapy in Glasgow

1NHS Staff

2About You

3Contacts

4Work

5Referral

6State of Wellbeing

7Sessions

8Referrer

9Submit

A Service for NHS Lanarkshire Staff

This online self-referral service is provided to NHS Lanarkshire staff.

We also offer a service for private individuals who wish to self-refer to speak to one of our team.

Are you a current employee of NHS Lanarkshire?*

Private Individual Referral

Unfortunately, this service is for NHS Lanarkshire staff only.

Please use our private individual referral service to access support.

Private Individual Referrals

Referral Type*

Please fill in all fields with the referred's details - you will have an opportunity to fill in your details before submitting.

Name*

First Last

Phone*

Email*

How Do You Identify?*

Date of Brith*

DD slash MM slash YYYY

Address*

Street Address Address Line 2 City Post Code

Your GP

GP Name or Name of Surgery*

GP Phone Number

Surgery Address

Street Address Address Line 2 City Post Code

Your Emergency Contact

Emergency Contact Name*

First Last

Emergency Contact Phone*

Your Relationship to the Emergency Contact*

Which area are you from?*

Which Directorate-HSCP are you from?*

Which job family to you belong to?*

What is the Reason for Your Referral?*

Do you have a medical or mental health diagnosis that you are aware of?*

Do you consider yourself to be at risk of harm to self or to others at this time?*

Are you currently considering suicide?*

Have you made a plan to end your life?*

For urgent mental health support please contact your local GP or NHS 24 on 111.

Or contact one of the following crisis services:

Samaritans: 116 123
Breathing Space: 0800 83 85 87
Scottish Women's Aid: 0800 027 1234
Rape Crisis: 08088 01 03 02

Are you considering or engaging in self harm?*

Are you currently receiving treatment or support from another service?*

Are there any barriers that would stop you from accessing weekly treatment?*

Are you currently attending work?*

What would be your session preference?*

Online - Via Video Calling

Please note we no longer offer face to face sessions, only video calling sessions.

When would be a good time for your sessions?*

Monday Morning

Tuesday Morning

Thursday Morning

Wednesday Morning

Friday Morning

Monday Afternoon

Tuesday Afternoon

Wednesday Afternoon

Thursday Afternoon

Friday Afternoon

Monday Evening

Tuesday Evening

Wednesday Evening

Thursday Evening

Friday Evening

Select as many as you wish

What is your relationship to the referred?*

Referrer Name*

First Last

Referrer Phone*

Referrer Email*

Consent of the Referred*

I confirm that I have the consent of the referred to submit a referral on their behalf

Is there anything you would like to add?

How did you hear about The Talking Rooms?

Personal Data Consent*

I confirm that I have read and understood how the personal data submitted in this form is handled and retained The Talking Rooms' Privacy Policy .

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