Referral form for CNWL staff

What is your full name? Required

What is your telephone number? Required

What is your email address? Required

What is your date of birth? (please use calendar below) Required

How do you identify your gender? Required

What is your ethnicity? Required

Do you have a disability? Required

Yes

Do not wish to disclose

If you wish to give details about your disability, please specify in the text box below

Do you have carer responsibilities? Required

Yes

Do not wish to disclose

What is your home postcode? Required

Are you happy to share which best describes your job role?

If job role is not listed above, please share:

Are you happy to share which division you work in at CNWL?

Which of the following describes what you are looking for?

Self-help materials

Accessing talking therapies (Counselling, Cognitive Behavioural Therapy)

Unsure (you might feel it would be useful to talk a bit more about your options)

Have you accessed support from Keeping Well previously?

Yes

Unsure

Are you currently accessing mental health support from any other service?

If you selected yes, please state where (if you are comfortable sharing)

Are you currently in the midst of a grievance/disciplinary proceeding/fitness to practice investigation? Required

How did you hear about the service?

Occupational Health

Manager

Internal trust comms/newsletter

Internal trust psychological support service

Colleagues

Workshops/webinars

Social media

Other

Accessing Talking Therapies

If you would like to access talking therapies, please note that we work in partnership with the below NHS Talking Therapies services in North West London:

Central North West London Foundation Trust – Brent, Milton Keynes, Harrow, Hillingdon, Kensington and Chelsea, Westminster.
West London NHS Trust - Hounslow, Ealing and Hammersmith & Fulham

If you do not wish to be contacted by one of these services then please let us know and a member of our team will contact you

I do not wish to be contacted by a CNWL Talking Therapy Service

If you have any queries or concerns about accessing these service please do contact us at cnwl.keepingwell@nhs.net

Do you work for CNWL? You can only submit a form if you work for the Trust Required

I confirm that I am a member of staff at CNWL (Central and North West London NHS Foundation Trust)

I agree to the privacy policy

Accessibility tools

Referral form for CNWL staff

Accessing Talking Therapies