Self Referral Form

Personal Details

Further Details

We gather further information on role and organisation to better inform our services and the care we are providing. We will not share any details with your workplace unless it is agreed after assessment that an occupational health referral is needed.
The next step is we will call you for a telephone assessment to find out more about your difficulties and discuss next the support options available.
Assessments are available Monday - Friday, between 8am and 4.15pm.
Please specify your availability for a telephone assessment e.g. Tuesday 10-11, Friday 9-3.30pm, or 'Monday' or 'anytime'.
(If you would prefer to speak to us before arranging this, please call us on 020 3228 3563 or email
Please note we always share information about risk with GPs. Even if you select no here, any risk concerns will be shared with your GP.