Long Term Health Conditions referral form :: Blackpool Teaching Hospitals

Next of kin / emergency contact details relationship

Next of kin / Emergency contact details contact number

Other, please give details

Does the patient have any support around their mental health problem? (Already involved with mental health services?) Please give details:

What is the impact of the patient’s mental health problem on their physical health?

Does the patient have any physical health needs that may impact on them attending sessions?

Are there any risks to be aware of? (Suicidal thought/self-harm/neglect/substance misuse)

Please sign the statement below if you give your consent for information to be shared. Required

I give my consent for the information contained in this referral to be shared with the NHS Blackpool Talking Therapies team.

Long Term Health Conditions referral form