Referral Form
Please fill out the following form to refer to JSK Psychological Solutions
Reason for Referral
Psychological Assessment
Psychological Therapy
Full Name
First Name
Last Name
Email
example@example.com
Phone Number
-
Area Code
Phone Number
Address
Street Address
Street Address Line 2
City
County
Postal Code
Date of Birth
-
Month
-
Day
Year
Date
Gender
Please Select
Male (including Trans Man)
Female (including Trans Woman)
Non-binary
Other
Name and Address of GP
GP Name
GP Surgery Address
Employment Status (Please select):
Employed - Full-Time
Employed - Part-Time
Self Employed
Unemployed
Student
Retired
Other
Emergency Contact Details
Full Name
Contact Details
Relationship to you
Current / Previous Medical Concerns
Previous physical and mental health problems
Current Medication (Name / Dosage)
Medication prescribed for your mental health
Have you had previous psychological care or counselling?
*
Yes
No
If Yes, If yes, please give the name of the clinician (s), the months you saw them (e.g., Nov 15 – Jan 16), and the nature of the difficulty at the time
Have you ever been admitted or hospitalised due to your mental health?
Yes
No
If yes, please give the dates and the nature of the difficulty at the time.
Please tick all the options that describe your current symptoms:
Low Mood /Depression
Constant Worry
Social Anxiety
Trauma Symptoms (Nightmares, Flashbacks, Intrusive Memories etc)
Avoiding Places or People
Mood Swings
Interpersonal Problems
Mood Swings
Low Self Esteem
Relationship difficulties
Obsessive Thoughts or Behaviours
Delusions or Hallucinations
Paranoia
Perfectionism
Violent Thoughts
Suicidal Thoughts / Attempts
Other
Please provide details of the reason for your referral:
Please verify that you are human
*
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