Client Service Receipt Inventory Please E-mail back to – talkingtherapies@berkshire.nhs.uk First Name(s) Last Name(s) Date of Birth: Today’s Date: Have you seen any of the following healthcare Where did you Number of professionals in the last 3 see this contacts in Reason for Attending months? healthcare the last 3 (Please tick for yes; leave professional? months blank for no) GP Practice Community Centre General Practitioner (GP) …….. Hospital Outpatient My own home GP Practice Community Centre Practice Nurse …….. Hospital Outpatient My own home GP Practice Community Centre Physiotherapist …….. Hospital Outpatient My own home GP Practice Community Centre Occupational Therapist (OT) …….. Hospital Outpatient My own home GP Practice Community Specialist (e.g. cardiac Centre …….. nurse, diabetes nurse) Hospital Outpatient My own home Doctor other than GP for a GP Practice physical health problem (e.g. Community cardiologist, Centre
Client Service Receipt Inventory – Please E-mail back to talkingtherapies@berkshire.nhs.uk First Name(s) Last Name(s) Date of Birth: Today’s Date: Have you seen any of the following healthcare professionals in the last 3 months? (Please tick for yes; leave blank for no) Where did you see this healthcare professional? Number of contacts in the last 3 months Reason for Attending General Practitioner (GP) GP Practice …….. Community Centre Hospital Outpatient My own home Practice Nurse GP Practice …….. Community Centre Hospital Outpatient My own home Physiotherapist GP Practice …….. Community Centre Hospital Outpatient My own home Occupational Therapist (OT) GP Practice …….. Community Centre Hospital Outpatient My own home Specialist (e.g. cardiac nurse, diabetes nurse) GP Practice …….. Community Centre Hospital Outpatient My own home Doctor other than GP for a physical health problem (e.g. cardiologist, GP Practice Community Centre
ClientServiceReceiptInventory.docx