Self-referral form

Please note that in order to access our service you will need to be registered with a GP in the London Borough of Ealing. If you are unsure which IAPT service covers your area, please either use this link therapies (IAPT)/LocationSearch/10008 or arrange to speak to your GP.
In response to the COVID-19 pandemic, if you work for the NHS or in a care setting in North West London*, you may also be eligible for our support via our priority service. For further information visit:
*Hammersmith & Fulham, Hounslow, Ealing, Harrow, Brent, Kensington & Chelsea, Westminster, Hillingdon.
Any information that you share with the Ealing IAPT service will be treated in strict confidence in accordance with the provisions of the DataProtection Act 1998.
We collect demographic information, such as religion and sexual oriention to make sure we are providing an equal service for everyone.
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If you are a Health Care Professional, please complete the below details

Personal Details

Please note: We will use your email address to confirm appointments, send you questionnaires relevant to your presentation, and a patient experience questionnaire after your assessment and end of treatment. If you do not have an email address or do not wish to provide one, please input the following above:

Demographic information

GP Details

Please note that we can accept referrals only for patients who are currently registered with a GP in the borough of Ealing.

Next of kin details

Please indicate below if you would like to nominate a next of kin. Your chosen person will only be contacted in an emergency and will be able to act on your behalf if you are unable to communicate with us.
If yes, then please provide their contact details below.

Further Information

Ealing IAPT is a 9am – 5pm service and unable to provide urgent support. If you are worried about immediate risk of harm to self or others, please contact the West London NHS Crisis Line on 0300 1234 244, call the Emergency on 999, or the Samaritans on 116 123. Alternatively, please present to your nearest A&E department.
If you currently have a diagnosis of psychosis, schizophrenia, or a personality disorder, please make an appointment with your GP who will be able to refer you to the most appropriate service. Similarly, if you have had a recent admission to a psychiatric unit, please speak to your GP or care coordinator.
If we decide that we are not the most appropriate service for you, we may send your details to another service that may be more appropriate.
If we have concerns about your safety, we have a duty of care to liaise with appropriate healthcare professionals (GP, care co-ordinator, Psychiatrist, Nurse, etc) to ensure that necessary support is arranged.
The Department of Health monitors all IAPT Services, as well as other NHS services, to check quality standards are similar everywhere. The Health and Social Care Information Centre (HSCIC) is the organisation responsible for providing reports on service data to the Department of Health. They monitor how many people are referred to services, waiting times and recovery. In order for them to do this, we send summary reports of the work we do to our commissioners. This numerical data includes no information that could reveal an individual's identity and the information is stored securely. You can find out more at or, or by calling the HSCIS patient line on 0300 456 3531. Alternatively, you can discuss this with your clinician.

What will happen next

Your self-referral will be reviewed by a member of the team and if we are the most appropriate service for you, one of administrators will call you to book you in for a telephone assessment with one of our therapists. If based on the information you have provided us with, we think that another service would be best placed to support you, then we will contact you to let you know. If you have any questions about any of this, please do not hesitate to call on 020 3313 5660 or email us on