Online Referral Form Please complete the form below to refer yourself. Please enable JavaScript in your browser to complete this form.Are you completing this form for yourself or on behalf of someone else? *I am completing this form for myselfI am completing this form for myselfI am completing this form for a friend or family memberI am a GP completing this form for my patientI am a healthcare or social worker completing this form for my patient/clientI am completing this form for someone else and my profession or relationship to them is not listedIf completing on behalf of someone else, please ensure that you have their consent.Name *FirstLastDate of Birth *Sex *MaleFemaleOtherPreferred PronounsHe / himShe / herThey / themOtherEmail *Address *Street Name and NumberAddress Line 2Address Line 2City / Town *City / TownPostal Code *Postal CodeContact Number *Preferred Therapy Medium *Online VideoPhoneFace-to-FaceResearch suggests therapy delivered online is similarly effective to face-to-face. Please note, certain therapies may not be available by phone, and availability of face-to-face appointments depends on location.Clinical Psychologist PreferencesDo you have any preferences in relation to the Clinical Psychologist you see? For example, do you have a preference as to their gender or is there a particular Clinical Psychologist you would like to see? Please note, this is subject to availability and specialisms.Any Other PreferencesFor example, in relation to the type of therapy you would like.Anything you feel your Clinical Psychologist should be aware of?For example, reasonable adjustments or any visual/hearing difficulties or neurodiversity (e.g. ADHD or dyslexia).Please provide brief details of why you are referring yourself to The Lexicon Therapy Practice (see information below text box) *If possible, please include: (1) what your main difficulty is that you would like help with, (2) how long have you had this difficulty, (3) any mental health diagnoses (e.g. PTSD, OCD), (4) what your goals are or what you hope to achieve from therapy.Do you give us permission to speak to another person (e.g. friend, next of kin) in the event of an emergency? *YesNoIf 'Yes' to above, please detail:Their nameIf 'Yes' to above, please detail: (copy)Their relationship to you (e.g. husband, brother, friend etc.).Contact Number (NOK)Their contact numberDo they live at the same address as you?YesNoHave you accessed talking therapy before? *YesNoHave you accessed any mental health services before? *YesNoThis includes crisis or home treatment teams, community mental health teams, psychiatry etc.Are you currently receiving any psychotherapy or mental health support? *YesNoAre you currently under any services? *YesNoSuch as community mental health teams, social services etc.Have you ever attempted to end your life? *YesNoPrefer not to disclose at this timeHave you had serious thoughts of ending your life in the past month? *YesNoPrefer not to disclose at this timeAre you taking any prescribed psychiatric medication? *YesNoFor example, anti-depressantsDo you have any physical or long-term health conditions? *YesNoDo you have any substance use difficulties? *YesNoDrugs (including alcohol), both prescribed and non-prescribed etc.I have read and agree with the contract for therapy *YesPlease click here to download and view the contractI am happy to be contacted by phone or email *YesI am happy for voicemails to be left *YesNoDrugs (including alcohol), both prescribed and non-prescribed etc.Submit Multiple Locations Online & Face-to-Face Phone +(888) 695-9859 Email [email protected]
