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RIGHTSTEPS TELEPHONE COGNITIVE BEHAVIOUR THERAPY REQUEST NOTES TO MANAGERS: Please complete the form below providing the information requested. You should advise the employee that you are making the request and explain to them why it is being made. It is essential that employees understand that they are being referred to the Rightsteps programme and failure to address this may delay contact being made. send to: Turning Point, Rightsteps Wellbeing, 44 Sidney St, Sheffield S1 4RH or email to: rightstepswellbeing@turning-point.co.uk I have discussed this with the employee and explained the reasons for referral into Rightsteps Cognitive Behaviour Therapy. (We cannot book the sessions if this box is not ticked) COMPANY NAME REFERRING MANAGER DEPARTMENT/SERVICE TELEPHONE FAX TITLE HOME ADDRESS POSTCODE

POSITION ADDRESS DATE MOBILE E-MAIL EMPLOYEE DETAILS FORENAME

SURNAME

DATE OF BIRTH TELEPHONE MOBILE DEPARTMENT E-MAIL PREFERRED PREFERRED CONTACT CONTACT NUMBER TIME ARE YOU CURRENTLY OR HAVE YOU EVER RECEIVED TREATMENT IN RELATION TO YOUR EMOTIONAL WELLBEING? YES NO (IF YES, COMPLETE THE GP SECTION BELOW) EMPLOYEE’S GP DETAILS DOCTOR’S NAME SURGERY ADDRESS TELEPHONE E-MAIL MANAGERS NAME

SIGNED

DATE

CLIENT INFORMED CONSENT - I agree for the above information to be disclosed to Turning Point and my current employer. I understand that I will be referred for assessment and potential treatment in relation to my emotional health and wellbeing. CLIENTS SIGNATURE DATE


Sample Referral form