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Female Sexual Function Service Referral Form

Please do not hesitate to contact us on 0300 304 0077 if you are uncertain about this referral, our service descriptions and referral criteria.

Inclusion Criteria

We will accept referrals as long as the following criteria are met:

FEMALE ONLY SERVICE. A confirmed diagnosis of female sexual pain/penetration difficulties.
Resident of Brighton and Hove.
Over 18 years old.
Consultant referrals only. No GP referrals.
Patient presentation deemed too complex for primary care psychological therapies services.

Female Sexual Function Service Referral Form

Referrer Information

Referrer Name:*

Referrer Email Address: *

Referrer Phone Number: *

Please confirm your email address:

Patient Information

Patient Name:*

Date of Birth: *

Address:*

Phone Number:*

NHS Number:*

Clinic Number:

GP Details:

Consent given to contact GP:*

Yes

Unsure

Reason for Referral

Reason for referral:*

Is the patient currently seeing any other counsellors, therapists, psychiatrists or psychologists?

Please list all prescribed medications:

Description of problems, ensuring this is associated with reason for referral, plus history/presentation of problems (previous difficulties and relevant prior life events):*

Background information (social situation, relationships, physical health, substance use):*

Any other information:

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