Self Referral Form

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

In order to reduce your wait for the service, we now work in partnership with Xyla Digital Therapies. This service offers timely assessments and treatments.
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.