NPS VCSE Referral Form

VCSE/SHSC Waiting List Referral Form

This form enables you to apply to gain support from No Panic Sheffield for support groups in 2022.
Name of participant

First NameLast Name
Name of Referrer

First NameLast Name
From waiting list

SPA/EWSRecovery
Contact email of the patient
example@example.com
Postcode of the patient

Street Address

CityCounty

E.g. S1 1AA
Contact Phone Number

Area CodePhone Number
Which support are you applying for:

Wednesday 6:30-8:30pm blended (on-line option)Wednesdays 6:30-8:30pm blended (face-to-face)Thursdays 10am-midday (face-to-face)
Do you consider yourself to have:

AnxietyDepressionLow mood
How long have you had anxiety/depression/low mood/other?
Which of the following do you have? Please tick if any

General Anxiety DisorderOCD (including trich and BDD)Post-traumatic stress disorderEUPD/Borderline Personality Disorder/BPDSocial anxietyAgoraphobiaDepressionOther personality DisorderSpecific PhobiaPostnatal depressionBipolar disorderOther
Could you describe the wellbeing/mental health needs the person being referred has and any details we need to be aware of e.g. person needs to attend with carer, any ongoing support or care. This includes in a group setting as we do not do 1-1.
How can we ensure he/she/they is able to access the sessions and feel included. We want everyone to feel safe and comfortable so do tell us anything that will help them to feel at home and welcomed.
Please list any things you are happy to disclose that anxiety prevents you from doing
e.g. social situations, work, leaving the house
Have you ever had in the past, or presently:

An Eating disorderDependence or addiction to a prescription medicationDependence or addiction to alcohol or other drugsOn medication currentlyWas on medication in the past (not currently)
Have you ever had a 'talking therapy'? Tick if yes.

Cognitive Behavioural TherapyDialectical Behavioural Therapy (DBT)Trauma focussed therapyEMDRCounsellingOther
If you have have had a talking therapy, how helpful was it?
What are the best ways to make contact with you?

EmailPhone call
Would you like to be on our mailing list? This is mostly for session information and a means of informing you if sessions are cancelled.

YesNo
By signing this form, you are giving consent to receive our service - No Panic Sheffield Self Help Group - and to be contacted via e-mail or telephone by No Panic Sheffield with information about our organisation and our meetings. We will not pass your details on to anyone else.
Signature

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VCSE/SHSC Waiting List Referral Form