Self Referral Form

Please note, this form is only to be completed by the person seeking help from NHS Talking Therapies.
We cannot accept referrals from third parties online (including friends and family).
If you are a health professional and you would like to make a referral, please contact the local team (please see for contact details)
Our service offers treatment for mild to moderate common mental health problems such as anxiety and depression. Please be mindful that it is not an urgent care or crisis service and your responses on this form may not be seen until you are booked in to speak to a clinician. If you are feeling unsafe please call our Mental Health Crisis Line which is available 24 hours a day, 7 days a week by calling 0800 953 0110.
NHS Lancashire and South Cumbria Talking Therapies cover the following GP practice areas in Lancashire (Blackburn With Darwen, Chorley South Ribble, East Lancs, Fylde & Wyre, Greater Preston, Morecambe Bay and West Lancs).
Please note the Furness & South Lakes teams only see adults (18+) who are registered with GP Practices within the area. If you are younger than 18 or registered with a practice outside these areas please contact your GP or visit for details of similar services to meet your needs.
If these are not an area that you are registered with please visit: to find your local talking therapies service

Personal Details

Please leave at least one contact number below.
NB: We will do our best to match the time of day selected, however not all teams have the capacity to offer evening appointments.
(please only add if you are happy for us to contact you via email when necessary and to send correspondence to this address)

GP Details

Further Information

Please note that we are not a diagnostic service (for example we do not provide diagnostic assessments of Autism, ADHD, Learning Disability or specific Mental Health diagnoses such as Bipolar Disorder).
The NHS regularly takes part in research on how to improve the experience of patients and the effectiveness of treatment. Please tick yes if you are be willing to allow our researchers to contact you about participating in future research. You can withdraw your consent at any time. If a researcher contacts you will be asked for your consent again before taking part in research.
NHS Talking Therapies is not an urgent service and cannot support people who are in crisis, if you need urgent support please find your local services here
I consent to you contacting the relevant GP or other services for further information if required in line with NHS Confidentiality agreements. I am aware information will be stored on a database.