Hello,

I'm writing to the practice to request a referral to ###INSERT SERVICE HERE###.

I am writing in the first case, rather than attempting to obtain an appointment by calling at 0815, because I recognise the enormous pressures that the practice and other NHS services are under.

If I receive no response, by email or phone, to this email by the morning of ###INSERT DEADLINE HERE### then I will attempt to obtain an appointment by calling at 0815 that morning. Please can you ensure that this email is placed in my patient notes.

Identification and Contact
My full name is ###INSERT FULL NAME HERE###. My date of birth is ###INSERT DOB HERE e.g. 01 January 1979 ###. My postcode is ###INSERT POSTCODE HERE###.

I can be contacted on ### INSERT MOBILE PHONE NUMBER HERE e.g. 07712 345 678 ### .

### THIS ISN'T VERY SECURE, BY EMAIL, BUT NEVER MIND ###

PHQ-9 and GAD-7 scores

As of the evening of Tue 2nd August, my scores on the following assessments were as follows:
PHQ-9: ###INSERT SCORE HERE### out of 27
GAD-7:  ###INSERT SCORE HERE### out of 21

### YOU CAN DO THESE ONLINE ###

Suicidality and self-harm
### DESCRIBE HERE IF YOU HAVE ANY THOUGHTS OF KILLING YOURSELF, HAVE MADE ANY PLANS TO DO SO OR HAVE ENGAGED IN SELF-HARM ###

### IF YOU HAVE *NOT*, SAY THIS ###

Request

### EXPLAIN HERE WHAT YOU WANT ###

### TRY TO IDENTIFY A SPECIFIC SERVICE, ASSESSMENT OR TREATMENT THAT YOU WANT ###

Medication
### DESCRIBE HERE IF YOU ARE CURRENTLY PRESCRIBED ANY RELEVANT MEDICATIONS ###

### DESCRIBE IF YOU CURRENTLY TAKE THEM RELIABLY ###

### SAY IF YOU ARE HAPPY TO CONTINUE WITH THIS MEDICATION OR IF YOU WANT TO CHANGE IT ###