Online Referral Form

Thank you for confirming that you are happy to proceed with this referral. If anything changes, and you feel unable to keep yourself safe, we would recommend that you contact your GP or the CRISIS (0300 222 0123). For more information about crisis support, please click ‘here’.

GDPR and Confidentiality – If you would like to know more about how we use your data, please click ‘here’.

Self Referral Form
First
Last
dd/mm/yyyy
Address
City
County
Post Code
And/or Preferred Language
This may include information about how long you have been struggling and any support you may have had in the past. This can include a type of therapy you are interested in. This will be discussed in more detail when you have an assessment in the service so it does not have to be in-depth.
This could include another IAPT provider or counselling service, A Psychiatric Nurse in a GP surgery, the CRISIS Team, or Secondary Services (CMHT) such as Laurel House and St Martins or other.
This could include another IAPT provider or counselling service, A Psychiatric Nurse in a GP surgery, the CRISIS Team, or Secondary Services (CMHT) such as Laurel House and St Martins or other.
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