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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, Psychologist 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 (1-2 sessions)
    Psychologist (6-8 sessions)
    Psychosexual Therapy (6-8 sessions)
    • Positive and/or complex result manageme
    • Partner notificati
    • Index patients referr
    • STI information and concerns about diagnos
    • Sexual abuse - dependent on need.
    • HIV related 
    • STI obsessed 
    • “Worried well” high anxiety and low or no risk 
    • Liaison and facilitation, onward care, for example, mental health, addiction services, support services 
    • Historic or complex sexual abuse
    • Chemsex
    • Sexual dysfunction, problems with being sexual 
    • Sexual problems as a result of an STI 
    • Sexual orientation/ sexuality concerns

  • Referral

  • Hidden
    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.
    If no, please discuss this referral with the patient.

  • Patient/client details

  • 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.
  • 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

  • DD slash MM slash YYYY