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Thank you for using the online registration process for Talking Therapies.

Please note that this service is only available to you if you are registered with a GP practice in Uttlesford, Epping Forest or Harlow.

Please complete your details below and submit them by clicking on the Register button.
Anything marked with * is compulsory.

And please bear in mind, the more information you give us about your situation, the more effectively we’ll be able to tailor our services to your needs.

You will need to complete the questions in one sitting so before you start it will be useful for you to have the following information to hand:

  • Your preferred contact details including postcode
  • Name of GP Surgery
  • When and in what areas of West Essex you would prefer to be seen

Once you have completed the registration process you will receive a confirmation email to the address you have provided.

Please note the waiting time for therapy can be up to 4 weeks depending on your flexibility around appointment times and locations.

We will contact you as soon as we have a suitable appointment for you. If you have not heard from us within 4 weeks of registering please contact us on 01371 876641.

If you have any questions or difficulties with this process, or need further advice or help, please call 01371 876641 or send an email to talking@westessexmind.org.uk and we will be happy to assist in any way we can.

We look forward to hearing from you.

Alison Wilson
Chief Executive Officer
West Essex Mind

Account Details
Username *
?

This is a unique name that the system will use to identify you with. It could simply be your full name or a nickname but must be one that no-one else will have used as well. 'JohnSmith' may be too common for instance, so try 'JohnSmith2008' instead.

Password *
?
Tips for creating a secure password:

  • It should contain one or more numbers
  • Create a unique acronym
  • It should have both upper and lower case characters
  • It should be over 8 characters long
  • Include similar looking substitutions, such as the number zero for the letter 'O' or '$' for the letter 'S'

Things to avoid:

  • It should not contain personal information (name, birth date, etc)
  • It should not contain a common dictionary word
  • It should not contain keyboard patterns (asdf) or sequential numbers (1234)

Tips for keeping your password secure:

  • Never tell your password to anyone (this includes significant others, roommates, parrots, etc.
  • Never write your password down
  • Never send your password by email
  • Periodically change your password to a new one

Verify Password *
?

Please re-enter your password exactly as you typed it above


Personal Details
Title *
First Name *
Last Name *
Email
?

Lots of reputable internet companies provide free e-mail accounts on the web. To set one up, simply click on a link below to access some of the best known ones and register your details with them.


Verify Email
Opt in for email alerts
?

Not applicable for this service.

Home Phone Number *
?

Do not leave a gap when entering your phone number

Textphone
Mobile Phone Number
?

Do not leave a gap when entering your mobile number

Opt in for SMS alerts *
?

Not Applicable for this service.

Postcode *
?

Once you have put your full Post Code into the box, select 'Click to find' as this will automatically search the Post Code database for the Post Code’s full address. You will then simply have to select the correct house name or number from the list that is presented to you, and your address will automatically appear in the text boxes below.

 
Address Line 1 *
Address Line 2
Address Line 3
Town*
County
Gender*
Date of Birth*
?

Select the Day and the Month of your birthday and then type the year you were born in the final box as YYYY. E.g. 1983 or 1976.

National Insurance Number
?
Not required for this Service

Please indicate how you would prefer to be contacted by ticking
one of the following and providing the relevant details:

By phone: *
Preferred daytime phone number
Preferred evening phone number
By email: *
Email address:
By Skype: *
Skype name:
In writing: *
Same address as above:

If no, which address:

House no or name:
Address line 1:
Address line 2:
Town:
County:
Postcode:
If by phone or Skype, when is the best time for us to contact you?
 
If by phone, are you happy for us to leave a message on the numbers you have provided?
NHS number
British Armed forces indicator
Occupation
Employment Status
 
Do you speak fluent English?
If no, do you require an interpreter?
If Yes, in what Language?
Ethnicity
Religious Affiliation
Sexual orientation
What are your current personal circumstances?
 

Please provide us with details of your GP.

We would like to remind you that this service is only available to you if you are registered with a GP practice in Uttlesford, Epping Forest or Harlow.

GP's Name
GP Practice Name *
Address line 1:
Address line 2:
Town:
County:
Postcode:
Are you happy for us to share information about your use of the service with your GP? *
Please tick any of the following boxes that you feel apply to your present situation: *
 
Approximately when did this/these start:
TodayToday
If you have ticked Addiction/Dependency please specify:
Is your current condition a recurrence of something you have had previously:
Have you had contact with the Community Mental Health Team (CMHT): *
 
Please provide us with a brief description of any contact or support you currently have or have had from the CMHT:
Do you have a long-term physical health condition:
Other, please specify
Please tell us about this condition and how it impacts on your daily life:
Do you have difficulties with any of the following:
Please provide us with details of any medication that you are currently taking:
Is there anything you would like to tell us that may enable us to help you better?
Appointments may become available from Monday to Saturday, morning, afternoons and some evenings. Please indicate your availability by ticking as many boxes as possible: *
Please indicate which locations you are able to get to across West Essex as this may affect the length of time you have to wait: *
 
Please tell us about any access or mobility requirements that we need to take into account when considering a venue for your sessions:
Please tell us how you would prefer to receive your therapy sessions by ticking one or more of the following
Please tell us how you heard about this service:
 

Please answer every question in the following two questionnaires. We need all your answers to determine the correct service for you.

General Anxiety Disorder Questionnaire


This easy to use questionnaire is used as a screening tool and severity measure for generalised anxiety disorder.

Over the last 2 weeks have you been bothered by any of the following problems?


Feeling nervous, anxious or on edge
Not being able to stop or control worrying?
Worrying too much about different things?
Trouble relaxing?
Being so restless that it is hard to sit still?
Becoming easily annoyed or irritable?
Feeling afraid as if something awful might happen?

Patient Health Questionnaire


This easy to use questionnaire is used as a screening tool and severity measure for depression.

Over the last 2 weeks have you been bothered by any of the following problems?


Little interest or pleasure in doing things?
Feeling down, depressed or hopeless?
Trouble falling or staying asleep, or sleeping too much?
Feeling tired or having little energy?
Poor appetite or overeating?
Feeling bad about yourself - or that you are a failure or have let you or your family down?
Trouble concentrating on things such as reading the newspaper or watching television?
Moving or speaking so slowly that other people could have noticed? Or the opposite – being so fidgety or restless that you have been moving around a lot more than usual?
Thoughts that you would be better off dead or of hurting yourself in some way?

Confidentiality Agreement:


We are commissioned by NHS West Essex to deliver the Talking Therapies and Employment Support service in this area. NHS West Essex reserves the right to access information about the service if required.


West Essex Mind and Employ-Ability are committed to maintaining confidentiality. All information about you is held securely and not shared with anyone outside our organisation without your permission, or unless exceptional circumstances occur. If you wish to see the records we hold about you this can be arranged by request to the Chief Executive Officer of West Essex Mind.


If we believe there is a risk of harm to you or someone else we will inform the appropriate person (such as your GP or other health professional), but we would always endeavour to let you know about this in advance.


Your data is held electronically on a secure data base and will be retained with any associated paperwork for a period of 7 years.


When you are no longer using our services, we will inform the person who first referred you that you have finished working with us.


Declaration


I declare that the information provided by me is accurate to the best of my knowledge.


I hereby authorise West Essex Mind to store personal information related to Talking Therapies and Employment Support services provided to me and to provide access to this information to NHS West Essex as may be required.


If you are happy to accept the above terms and conditions and have finished completing the form, please tick the following box and click on the button marked Register. If your registration is successful you will progress to a screen entitled My Profile where you can edit the information you have provided. In due course, you will also receive an email confirmation from us.


I agree to the above terms and conditions and certify that, to the best of my belief, the information I have supplied is true and complete. I understand any false or misleading information may disqualify me.
Tick to agree


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