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Psychological Therapy Service referral form

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Sexual Health - Psychological Therapy Service referral form

Referral criteria

For all referrals to the Health Advisors and Psychosexual Therapy Service, please provide the details below to the best of your ability. Please feel free to contact members of the services prior to your referral to discuss anything.

We will contact clients directly by phone and email to arrange an appointment. Please check this information is correctly recorded on Inform.

An outline of the patient’s current problem together with relevant medical history will help with making sure the client/patient is seen by the most appropriate service. If you are clear on which service you would like to refer to, then indicate this. If you are unsure, indicate this and the referral will be triaged and agreed by service members.

Guidance for selecting the right referral:

Health Advisors (1 to 2 sessions)
Psychosexual Therapy (6 to 8 sessions)
  • Positive and/or complex result management
  • Partner notification
  • Index patients referral
  • STI information and concerns about diagnosis
  • Sexual abuse - dependent on need.
  • Pain during sex
  • Arousal/orgasm disorders
  • Erectile issues
  • Ejaculatory issues
  • Low sexual desire

Referral

What service is this referral for?(Required)
Hidden
OLD Is this referral urgent?
Reasons for a referral to be urgent include: the level of distress the client is experiencing, situational, for example, is a partner about to be released from prison or on leave from the forces etc, opportunistic, for example. chemsex users deciding they need to give up now.
Has the patient/client consented to this referral?(Required)
If no, please discuss this referral with the patient.

Patient/client details

Name(Required)
Date of birth(Required)
Address(Required)
Can we contact the patient on this number?(Required)
Please confirm you have gained consent from the patient that they are happy to receive emails from our Psychological Therapy Service(Required)
We will contact clients directly by phone and email to arrange an appointment. Please include a phone number and email address where available.
Please check that the contact information that you have is the same as on Inform.
Without a clear psychosexual issue identified, your referral may be declined(Required)
Please tick all that apply.
Use the patients own words and description, include any additional information that you think may be relevant, for example, duration of the problem, any complexities caused by their living, working or family situation.

Referrer

Referred by(Required)
Address(Required)
DD slash MM slash YYYY