Self Referral Form

Complete this form to refer yourself for free and confidential treatment.
You can also refer by phone 01698 793 980

 

We’ll confirm your appointment details by email  or send a booking link by text, usually by 5 working days.

We ask questions which help us identify  areas where you are affected to ensure that we deliver a service that meets your needs.

If you need urgent mental health treatment call NHS 111 for advice. If your life is in danger, always dial 999

This form takes about three minutes to complete, questons marked with an asterisk are required,

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We keep the confidential information we send you to a minimum due to the risk of details being received by unintended recipients.

Emails from us may go to your spam folder.
 
Do you wish your GP to be made aware that you have been referred to Talking Therapies?

For video calls you will need a suitable device with a camera and internet connection and a confidential space at the time of your appointment.

We can offer an initial 40 minute appointment.

When you submit this form your details will be stored on our secure and confidential health record system.

Need help now?

If there’s someone you can talk to – a family member, a friend or a neighbour – ask if you can spend a few moments with them to help you relax.

If you or anyone else is in immediate danger or harm, please call 999

If you urgently need medical help or advice, but it’s not life threatening, please call NHS 111

If you want to talk to someone about how you feel, what you’re experiencing or how to deal with someone else’s behaviour, you can contact the Samaritans 116 123