Self Referral Form

V2

Personal Details

Please use the calendar to enter your date of birth or type it in the format 00/00/0000

GP Details

Please note we will inform your GP that we have received this referral.

Further Information

Referral Information

Please note we are not an emergency service. If you are worried about immediate risk of harm to self or others, please visit A&E at Princess Royal University Hospital or call the Oxleas Urgent Advice Line on 0845 608 0523. If you are not at immediate risk but would like support and advice, please visit your GP or call the Samaritans on 116 123.
Please be aware a therapist may call you to discuss your referral. Failure to speak to you may result in your referral not being processed. Please note our calls show as a withheld number. If we can’t contact you we will contact your GP.