Self Referral Form

V2
We are not a crisis service. If you need urgent support, please do not complete this form. Instead, please:
- contact your GP for an emergency appointment
- contact the Oxleas Urgent Advice Line on 0800 330 8590
- call the Samaritans on 116 123
- call 999
- Or go to your nearest A&E department

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 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.