Referral Form

Please note that in order to access our service you will need to either be a resident, or be registered with a GP, in the London Borough of Hammersmith & Fulham. If you are unsure which NHS Talking Therapies service covers your area, please either use this link: or arrange to speak to your GP.
In response to the COVID-19 pandemic, if you work for the NHS or in a care setting in North West London* you will be eligible for priority access to support. To access this, please complete the below referral form. For further information, visit
*Hammersmith & Fulham, Hounslow, Ealing, Harrow, Brent, Kensington & Chelsea, Westminster, Hillingdon.
Hammersmith and Fulham NHS Talking Therapies is not an emergency service and this referral form should not be used if you require urgent support. If you are worried about immediate risk of harm to self or others, please contact the following services 24 hours a day, 7 days a week: West London NHS Trust Helpline (0800 328 4444) NHS Helpline (111), and the Samaritans (116 123).
In taking your details, we recognise the importance of personal privacy and make sure all information about you is held securely in accordance with the General Data Protection Regulation (GDPR). We use data anonymously for monitoring purposes, however no one will be able to link any information back to you.
Everything you tell us is kept confidential, however if you disclose information concerning current or potential harm or risk to yourself or another, we may need to tell another party including your GP, the Police or Ambulance Service.
If you need support completing this form, please contact us on 0300 123 1156 or email
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If Referral from a Health Care professional is selected, please complete the below details

Your Details

Please note: We use your email address to confirm appointments only. If you do not have an email address, please input the following:

GP Details

Your GP has a key role in coordinating all the care you receive and so it is helpful to keep them up to date about whether you are accessing our service and other support you may need.
Please be aware that at times we may need to contact your GP without your consent. This is usually if we are concerned about your safety or the safety of someone else.

Referral Information

Please see the section on our webpage titled ‘Problems we treat' ( for information about the areas that we can and cannot help with. Please make sure to open this in a separate tab so that you don’t lose the information you have already provided.

Further Information

If yes, please provide the details of your carer below:

What will happen next

If we think we are able to help you we will offer you an assessment appointment with one of our team. If we think that you could benefit from a different service we will contact you to let you know. If we decide that we are not the right service to offer you therapy, we may send your referral to another service that may be more appropriate for you within our Trust.
If you have questions about how we manage your information, you are welcome to discuss these with any staff member involved in your care.