Self Referral Form

* indicates required field

Your Details

In the text fields below, please use only letters, numbers, hyphens, single quotes and spaces. Other characters may not be accepted.
Please use your full name - please do not use shortened names/abbreviations
You can only refer yourself to us if you are 16 or over.
Please enter a telephone number starting with 07 and containing no spaces

Emergency Contact

GP Details

Please note that if we identify any risk to yourself or to anyone else we may need to contact your GP regardless as part of our duty of care to ensure the safety of our patients and the people around them.

Your Personal Information

Reasons for referring yourself

To help us ensure we offer you the most appropriate treatment we need to know:
Upon receipt of your referral, you will be contacted by the service to arrange your initial telephone assessment appointment or we may discuss transferring your care with other services if we are not the appropriate service to meet your needs.
We are not a general mental health service and are not able to offer crisis management or general support to people. If, in the meantime you experience deterioration in your symptoms or are finding yourself struggling to cope, please make an appointment to see your G.P.