Let’s Talk iapt referral Form

Let’s Talk IAPT Referral Form
Improving Access to Psychological Therapies Service (IAPT) is a confidential NHS service providing easy access to psychological therapies for people experiencing depression and anxiety. To make a referral online, visit www.lets-talk-iapt.nhs.uk/refer.
Please ensure that you complete all of the fields

Name:					Date of Birth:			Gender: M / F
Address: Postcode:					GP Name: GP Address:
Date of referral:					Please note that your GP and Health Visitor (if applicable) will be kept informed of your referral.
Preferred Contact Number: ____________________________
					Interpreter required?		Yes  No 
OK to leave voice messages:			Yes  No 		If yes, in which language? ______________________
OK to send text messages:			Yes  No 		Is this is a self-referral?		Yes  No 
OK to communicate via email:			Yes  No 		If this is not a self-referral, please provide referrer’s name, address and telephone number if different from the GP details above.
Email: ____________________________________________
What is the main problem that you would like help with, and how is it affecting your life?
How did you hear about us?
GP		Other Healthcare Professional				Search Engine (e.g. Google, Bing)			
Leaflet		Workshop run by IAPT				Social media (e.g. Twitter, Facebook)			
Family/Friend		Other  Please specify……………………………

Once completed please return form to:

Send by post to: West Haringey IAPT 45 Middle Lane, Crouch End, N8 8PH Send by email to: [e-mail] Fax: [phone] Telephone number: 020 3074 2280 Website: www.lets-talk-iapt.nhs.uk

Send by post to: East Haringey IAPT 1a Lansdowne Road, Tottenham, N17 0LL Send by email to: [e-mail] Fax: [phone] Telephone number: 020 8808 5833 Website: www.lets-talk-iapt.nhs.uk

*If you are worried about acting on suicidal thoughts OR about hearing voices or other psychotic symptoms - Contact your GP or specialist mental health services via The Crisis Resolution and

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ome Treatment Team on 020 8702 6700 or go to your A & E.
Please see the list below to find the correct team for your GP practice.

West Team:		East team:
The 157 Medical Practice	N4 3PZ	The Bridge House Surgery	N4 1TL
Highgate Group Practice	N6 4QA	Hornsey Park Road	N8 0PH
The Surgery, 625 Green Lanes	N8 0RE	The Old Surgery	N8 0RP
Christchurch Hall Surgery	N8 8AE	The Surgery, 618 Green Lanes	N8 0SD
Crouch Hall Road Surgery	N8 8HJ	Havergal Surgery	N15 3DY
153 Park Road Surgery	N8 8JJ	West Green Road Surgery	N15 3PB
Queenswood Practice	N8 8SU	Lawrence House Surgery	N15 4JR
The Vale Practice	N8 8SU	Tynemouth Road Health Centre	N15 4RH
Allenson House Medical Centre	N8 9TB	Spur Road Surgery	N15 4AA
Rutland House Surgery	N10 1DU	JS Medical Practice	N15 4JR
Dukes Avenue Practice	N10 2PS	Philip Lane Surgery	N15 4AB
Queens Avenue Practice	N10 3BJ	The Laurels Medical Centre	N15 5AZ
Bounds Green Group Practice	N11 2PF	Laurels PMS Practice	N15 5AZ
Myddleton Road Surgery	N22 4NW	Grove Road Surgery	N15 5HJ
Stuart Crescent Health Centre	N22 5NJ	Fernlea Surgery	N15 6JR
High Road Surgery	N22 5JB	St Johns Surgery	N15 6QP
Arcadian Gardens Surgery	N22 5AB	St Paul’s Road Surgery	N17 0NJ
The Surgery, 26 Westbury Avenue	N22 6RS	Park Lane Surgery	N17 0JP
Westbury Medical Centre	N22 6RX	Broadwater Farm Health Centre	N17 6BF
The Alexandra Surgery	N22 7UN	Bruce Grove Medical Centre	N17 6QB
Evergreen House Surgery	N22 8JJ	Castle View Surgery	N17 6XE
Morum House Medical Centre	N22 8HE	Morris House Group Practice	N17 6AA
		Charlton House Medical Centre	N17 6SB
		Somerset Gardens Family Health Centre	N17 8NW
		Tottenham Health Centre	N17 8AH
		Dowsett Road Medical Centre	N17 9DL
Send by post to: West Haringey IAPT 45 Middle Lane, Crouch End, N8 8PH Send by email to: [e-mail] Fax: [phone] Telephone number: 020 3074 2280 Website: www.lets-talk-iapt.nhs.uk		Send by post to: East Haringey IAPT 1a Lansdowne Road, Tottenham, N17 0LL Send by email to: [e-mail] Fax: [phone] Telephone number: 020 8808 5833 Website: www.lets-talk-iapt.nhs.uk

*If you are worried about acting on suicidal thoughts OR about hearing voices or other psychotic symptoms - Contact your GP or specialist mental health services via The Crisis Resolution and

Home Treatment Team on 020 8702 6700 or go to your A & E.