Staff psychology service referral https://www.chelwest.nhs.uk/services/staff-psychology-service/staff-psychology-service-referral https://www.chelwest.nhs.uk/++resource++plone-logo.svg Staff psychology service referral User email: Please leave this blank!!! Please note this form is can only be used by staff with a valid nhs.net email address We offer psychological consultations, brief support for work-related issues and signposting. If you are unsure if our service is the right service for you or the person you are referring, or if you have any problems completing this form, please contact us to discuss this (staffpsychchelwest@nhs.net). The Staff Psychology Service is not a crisis service and is unable to provide urgent help. If you feel that you need to speak to someone about your mental health urgently please contact your GP surgery or call your local crisis team (via 111). Please call 999 or visit A&E in an emergency. Referral details Full name Job title Working hours Full time Part time Date of birth Gender Female Male Non-binary Ethnicity Asian/Asian British - Bangladeshi Asian/Asian British - Indian Asian/Asian British - Pakistani Asian - any other Asian background Black/Black British - African Black/Black British - Caribbean Black - any other Black background Mixed - White and Asian Mixed - White and Black African Mixed - White and Black Caribbean Mixed - any other mixed background White - British White - Irish White - any other White background Other - Chinese Other - any other ethnic group Prefer not to say Your ethnicity describes your cultural or ancestral heritage, which is inherited from your ancestors, your parents or grandparents. This may be different to your nationality, which is your legal identity, the country where you are a legal citizen. You may have been born in this country, or you may have moved here and became a citizen. Knowing your correct ethnicity is important to us as it helps us provide the best possible care for you as an individual. Home address City/town Postcode Email address This must be your nhs.net email address Contact number I consent to receiving voice messages from the Staff Psychology Service I consent to receiving sms/text messages from the Staff Psychology Service GP details GP name and address Work details Division Emergency & Integrated Care Planned Care Women’s Children, HIV, Gum & Dermatology Corporate/Enterprise/Clinical Support Enterprise Main site CW Hospital WM Hospital Cross-site Offsite/other Other site Only complete this if you chose offsite/other above Occupation Admin AHP Estate General Management Medical & Dental Nursing Sci/tech HCA Midwife Other Other occupation Only complete this if you chose other above Referral type Is this a self-referral? Yes No Referrer details Referrer role Manager HR OH Other Other referrer role Only complete this if you chose other above Referrer full name Referrer job title Referrer email This must be your nhs.net email address I confirm that the person I am referring has consented to this referral We can only accept referrals where consent have been explicitly given Referral reason Reason for referral Please provide as much information as possible so we can process your referral efficiently Additional support Any other help? Is any support or treatment currently being sought or accessed elsewhere? (eg by a psychological therapies or mental health service)? Please provide details below, including if you are on any waiting lists. Submit Contributors George Vasilopoulos
