Registration Form

If you would like to arrange an appointment please complete this registration form.

When we have received your completed form we will contact you to book a telephone assessment. We will contact you within two weeks of receiving your registration form. Please note this will come from a withheld number.

Your assessment will last 30 – 45 minutes and in preparation we ask that you consider what your main difficulties are that bring you to the service, and the impact this is having on your life. It would also be helpful if you could think about what you would hope to be different by coming to the service, and what you would like to improve or change for the better.

During your assessment you may be offered treatment options, and a decision made on the next steps of your care with us. Please note that the treatment you are offered may be in a group setting. We know that talking therapies treatments are most effective when the person is able to commit to regular weekly appointments, and we encourage you to consider your ability to commit.

As we are not able to offer an emergency response service, if you require more immediate support whilst you are waiting for an appointment you should contact your GP. Samaritans also offer a 24 hour telephone support service for persons experiencing distress. Their free phone number is 116 123.

 

If you have registered to attend a Stress and Mood Management Course, you do not need to complete this registration form.

Please note that this service is available to people aged 16 and over who are registered with a GP in South Gloucestershire only. If your GP surgery is in a different area, please ask your GP for further information. To find local GPs you can use the NHS GP finder.

Confidentiality
Any verbal and written information you provide us is treated sensitively. We carefully follow confidentiality guidelines, this includes a duty of care to share information with your GP and relevant professionals which may be important in protecting you or someone else from any sort of serious harm.

If you have any queries or concerns, please contact the team on 0117 378 4270.

 

If you would prefer, you can download a copy of our registration form and email it as an attachment to awp.SouthGlosTalkingTherapies@nhs.net or send it by post to South Gloucestershire Talking Therapies, 246 Station Road, Yate, BS37 4AF.

Downloadable Registration Form

 

Online Registration Form

Surname

Forename(s)

Date of birth

Gender
MaleFemale

Address

Postcode

Telephone No.

Can we leave messages?
YesNo

Mobile No.

Can we leave messages?
YesNo

Are you happy to receive text messages and reminders from our service?
YesNo

Email address

Can we communicate with you via email for written correspondence?
YesNo

Please let us know of any other persons you consent for us to share information with:
(e.g., family members, support worker)

Which GP surgery are you registered with?

Do you consider yourself to be a disabled person (or have a learning disability)?
YesNo
If yes, what is your disability?

Are you a carer for someone with a physical or mental health disability?
YesNo
If yes, what is their disability?

What is your ethnicity?

Are you able to communicate in English?
YesNoWith Support

What is your first language (if not English)?

Would you prefer to use an interpreter for your appointments with us?
YesNo

What is your sexuality?
HeterosexualBisexualLesbian/GayOtherUnknownPrefer not to say

Do you consider yourself to have a Long Term Health Condition?
YesNo
If yes, what is your condition?

Do you consider that you have any information or communication support needs?
YesNo
If yes, how do you feel that the service can best meet these needs?

Have you ever been a member of the British armed forces?
YesNo

Are you or your partner pregnant?
YesNo
If yes, what is your expectant due date?

Have you or your partner had a baby within the last 12 months?
YesNo

Are you currently on Probation/Licence?
YesNo
If yes, please give name of your Probation Worker:

Where did you hear about our service?


I confirm that I am registered with a GP surgery in South Gloucestershire