Self Referral Form

Please complete the following information which will help guide us to support you. We will contact you within 3 working days, if you would like to speak to someone sooner or are unable to complete the form please click the call back button or call us on 020 8637 6279, email us at or come and see at us our base at St. Charles Centre for Health & Wellbeing to make a referral.

Basic Information

Further Information

We would be grateful if you could share some more information with us (optional):
We will do the best we can to try to accommodate your preferences but where we are unable to, we will discuss this with you.