1 Carterknowle Road, Sheffield, S7 2DW

Telephone: 0114 229 1686

Sorry, we're currently closed. Please call NHS 111

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137 Dore Road, Dore, Sheffield, S17 3NF | Telephone: 0114 229 1686

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Routine Appointment Request – Mental Health

Routine Appointment Request – Mental Health

Please note - if you do not hear back from our team within 5 working days, please contact us, as your form may not have been submitted successfully

Name(Required)

Date of Birth(Required)

DD slash MM slash YYYY

Email(Required)

Phone Number(Required)

If you are not the patient above but are completing it on their behalf please give us your name and phone number should we need to speak to you?

Consent(Required)

I confirm I have read the below statement and my enquiry is not urgent(Required)

I confirm I am not reporting an acute infective illness that may require more prompt medical treatment such as urine infections, chest infections, tonsilitis, scarlet fever or illnesses where clinical response is needed urgently (Forms can take up to two working days to be seen and runs the risk that the condition is not treated in a timely manner. If your enquiry is relating to an infection or acute illness, this should be phoned through that day or advice sought from the walk-in-centre or 111 / GP out of hours services if we are closed).

Consent(Required)

I consent to the practice collecting and storing my data from this form.(Required)

THIS FORM COLLECTS YOUR NAME, DATE OF BIRTH, EMAIL, OTHER PERSONAL INFORMATION AND MEDICAL DETAILS. THIS IS TO CONFIRM YOU ARE REGISTERED WITH THE PRACTICE, TO ALLOW THE PRACTICE TEAM TO CONTACT YOU AND ALSO TO UPDATE YOUR MEDICAL RECORDS HELD BY THE PRACTICE AND OUR PARTNERS IN THE NHS. PLEASE READ OUR PRIVACY POLICY TO DISCOVER HOW WE PROTECT AND MANAGE YOUR SUBMITTED DATA.

Are you seeking an appointment with a particular person? If so with whom?

Our team will arrange an appointment on your behalf and text you to let you know when it is. Please advise your availability below. Many people want appointments at similar times so the more options you give us the sooner the date we can book the appointment for. Please note evening / weekend appointments have limited availability and you may wait for longer for an appointment if you only select this option.

Monday Mornings

Monday Afternoons

Tuesday Mornings

Tuesday Afternoons

Wednesday Mornings

Wednesday Afternoons

Thursday Mornings

Thursday Afternoons

Friday Mornings

Friday Afternoons

Evening Appointment Monday - Friday 18:30 - 21:30 (Carterknowle Surgery Only)

Saturday Mornings (Carterknowle Surgery Only)

Saturday Afternoons (Carterknowle Surgery Only)

What are you experiencing? (You can select more than one)(Required)

Feeling Anxious

Low Mood

Stress

Other

When did it start?(Required)

Has it changed? If so, in what way and over how long?(Required)

Does anything make it better or worse?(Required)

When does it occur?(Required)

How bad is it? (Consider a scale of 1-10 where 10 is the worst)(Required)

How is your sleep?(Required)

Normal for me

I sleep too well

I can't get to sleep

I wake in the early hours

Have you had this before?(Required)

Have you seen us about this before?(Required)

Have you tried any treatment for this?(Required)

Where do you get your support from?(Required)

Is there anyone you can talk to about how you are feeling?(Required)

How often do you have thoughts about harming yourself? if you are worried you may act on them in the near future or are planning to, please call us on 01142291686 or 111.(Required)

Never

Sometimes but I would never doing anything about them

Sometimes and I am worried I may act on them

Most of the time but I would never do anything about them

Most of the time and I am worried I may act on them

I plan to act on them

Other

Is there anything else you want to tell us about this or any more information you want to give us?(Required)

What is your occupation?(Required)

How much alcohol do you drink and how often?(Required)

How often do you use any substances like cannabis or cocaine or similar? Which, how much and how often?(Required)

Do you have any thoughts as to what the cause may be?(Required)

Is there anything you are worried about it with it? Including cause or consequence.(Required)

How would you like to us to help you? What were you hoping we can do?(Required)

Many people who contact us about mental health concerns can often be treated with support for a psychological well being practitioner. If we felt it was appropriate for you would you be happy for us to book you in directly with them? We advise everyone to visit their website https://www.sheffieldtalkingtherapies.nhs.uk/ to look at the options available to them?(Required)

Yes

I'll look at that website and access support directly so don't need the surgery to contact me.

No

Email

This field is for validation purposes and should be left unchanged.

75273

Zero Tolerance

Veteran Friendly

Carterknowle Surgery
Opening Times

Monday
08:30am to 12:30pm
01:30pm to 06:00pm
Phone lines close at 12:15 and reopen at 13:30
Tuesday
08:30am to 12:30pm
01:30pm to 06:00pm
Phone lines close at 12:15 and reopen at 13:30
Wednesday
08:30am to 12:30pm
01:30pm to 06:00pm
Phone lines close at 12:15 and reopen at 13:30
Thursday
08:30am to 12:30pm
01:30pm to 06:00pm
Phone lines close at 12:15 and reopen at 13:30
Friday
08:30am to 12:30pm
01:30pm to 05:00pm
Phone lines close at 12:15 and reopen at 13:30
Saturday
CLOSED
Sunday
CLOSED

Dore Surgery
Opening Times

Monday
08:30am to 12:30pm
01:30pm to 05:00pm
Phone lines close at 12:15 and reopen at 13:30
Tuesday
08:30am to 12:30pm
01:30pm to 05:00pm
Phone lines close at 12:15 and reopen at 13:30
Wednesday
08:30am to 12:30pm
01:30pm to 05:00pm
Phone lines close at 12:15 and reopen at 13:30
Thursday
08:30am to 12:30pm
01:30pm to 05:00pm
Phone lines close at 12:15 and reopen at 13:30
Friday
08:30am to 12:30pm
01:30pm to 05:00pm
Phone lines close at 12:15 and reopen at 13:30
Saturday
CLOSED
Sunday
CLOSED

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Staff Login | Privacy Policy | Accessibility

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Personal Details

Name*

First Last

Date of Birth*

Email Address*

Ethnicity*

CHANGE OF NAME

Previous surname

Please note we cannot change your name without a change of name document. This can be marriage certificate, deed poll etc. Our team will be in touch to ask you for this if you have requested to change your name.

How do you wish to be known?

Dr

Mrs

Mr

Miss

Ms

Other

CHANGE OF ADDRESS

Previous Address, including postcode

New Address, including postcode

Please list all family members moving with you

UPDATE CONTACT NUMBERS

Do you consent to being reminded by text for appointments?

Yes

No

Are you a carer?*

Yes, I am a carer for a friend/relative

Yes, I work as a carer in a residential/care home or community setting

No

Number Type

New Phone Number

Comments

This field is for validation purposes and should be left unchanged.

58096

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