IAPT Psychological Therapies and Employment Support

Referral form for GPs

THIS IS NOT AN EMERGENCY SERVICE.
If there is an ACTIVE RISK of harm to self or others, please refer to Single Point of Access -  wlm-tr.wlmhtspa@nhs.net

Please see below the form for quick reference guide. 

Patient

DoB
Patient’s Address
Interpreter Required Required
Does the patient have a learning disability? Required
Any mobility difficulty? Required
Due Date/Babies Date of Birth

Referrer

Required
Required
Required
Referrer Address Required
Required
Required
Required
Required
Date of Referral Required

Required if different to referrer’s details above

Contacting the patient

Is it ok to call/leave a message on the home number? Required
Is it ok to call/leave a message/text on mobile number? Required
What service do you think the patient needs: Required
Required

Main presenting problems, history of presenting problems and any relevant context

Patient medical/medication history

Include all relevant results or letters and any other information you think is relevant.

Start date - Drug name

Last issued - Drug name - Dose

Additional information

Is the patient currently taking any medication for mental health? Required
Date
Date
Any current or previous use of mental health services/ counselling? Required
If referring for support for LTC e.g. diabetes, respiratory or cardiac, is your patient under any hospital or community services? Required
Any concerns about drug/alcohol use? Required

Risk of Harm To Self (e.g. suicidal ideation, suicide attempts; self-harm; self-neglect)

Consider referral to Single Point of Access - wlm-tr.wlmhtspa@nhs.net

Current? Required
History? Required

Risk of Harm From Others (e.g. domestic violence, bullying)

Consider referral to Single Point of Access - wlm-tr.wlmhtspa@nhs.net

Current? Required
History? Required

Risk of Harm To Others (e.g. violence, aggression, risk to children)

Consider referral to Single Point of Access - wlm-tr.wlmhtspa@nhs.net

Current? Required
History? Required
Do they have any dependent children (under 18 years) living with them? Required

To help us prioritise in line with NICE guidelines, please answer the following:

Is the patient pregnant or <1yr postnatal? Required
Is the patient a war veteran? Required
Required

Hounslow IAPT quick reference guide

Individuals with mild to moderate depression and anxiety disorders, including: 

  • OCD
  • Generalised anxiety/excessive worry 
  • PTSD (following a single traumatic incident) 
  • Panic attacks
  • Social anxiety 
  • Low self-esteem
  • Anger or irritability (with low risk to others)
  • Health anxiety
  • Specific phobias
  • Post-natal depression and/or anxiety
  • Difficulties adjusting to living with a long-term health condition 
  • Low level of risk to self or others 
  • Motivated to attend psychological therapy

  • Group-based therapy or psychoeducational workshops
  • Group-based interventions for specific long-term health conditions (diabetes, respiratory & cardiac conditions)
  • Guided self-help
  • Cognitive behavioural therapy
  • Online CBT (My Mind Matters)
  • Counselling
  • Interpersonal Therapy (IPT)
  • Behavioural Couples Therapy 
  • Eye Movement Desensitisation and Reprocessing (EMDR)

A significant number of clients are treated in a group therapy/workshop setting.

  • Active risk of harm to self, a recent suicide attempt or in crisis
  • Active risk of harm to others or recent history of violence
  • Diagnosis of a severe & enduring mental health disorder (e.g. bipolar disorder, psychosis, schizophrenia)
  • An active personality disorder diagnosis or PD traits that would make brief psychological therapy likely to be unhelpful
  • Complex needs requiring multi-disciplinary/longer-term psychological input e.g. chronic agoraphobia, PTSD resulting from repeated/ongoing trauma or torture
  • Drug/alcohol use at a level that may impact therapy
  • Significant psychosocial or physical health factors or social instability (e.g. housing problems) that would prevent engagement in regular therapy or require MDT input.
  • Where ongoing home visits are required
  • Individuals who are under secondary care mental health services

  • Primary Care Mental Health Service
  • Secondary care services (via Single Point of Access)
  • Eating Disorders Service
  • Perinatal Mental Health Service (if pregnant or baby under 6 months)
  • Long-term, low cost psychotherapy/ counselling (e.g. Open Door/ Phoenix, Metanoia)
  • Non-statutory services, e.g. Women & Girls Network
  • Practical support, e.g. Hestia Life
  • Drug & alcohol services

  • Description of the presenting difficulty
  • Details of any current or previous risk to self and risk management plan
  • Details of any current or previous risk from others
  • Previous or current input from other services
  • Any current safeguarding concerns

Where urgent input is required or there is active risk of harm to self or others, referrals should be sent to the West London NHS Trust Single Point of Access

Unsure whether to refer?

Please contact 0300 123 0739 or email houccg.hounslowiapt@nhs.net to discuss any queries with a clinician.