Self Referral Form

Self Referral Form

Brief questions to help understand the support that would suit you.
Please let us know if you want support to complete the form.
Confidentiality: Just so you know – if in working with us we become aware that you or a 3rd party is at risk then we will need to inform relevant agencies to ensure that the right support is provided.

Personal Details

GP Details

Additional Info

Thank you so much for providing that detail – the referral will be discussed with a team leader to ensure the appropriate team contacts you in due course.
We provide some care in partnership with digital therapy providers (Xyla Digital and IESO). If necessary, we might share information about you with these providers so that they can support us to provide your care.