Self Referral Form

Patients Details


Contact Details

Please note that Tower Hamlets Talking Therapies will be calling from a withheld/private number. We will only leave a message if you have given us permission to do so.

Emergency Contact Details

Please share the details of someone we can contact in the event of an emergency. We would only ever contact this individual where we have concerns about yourself in order to help you find the correct immediate support and this is a requirement to be seen within our service.


Registered GP Details

By referring yourself to this service you are agreeing that the service may contact and share relevant information with your GP to facilitate your care