Self Referral Form

Your Details

Please use your full name as it appears on your birth certificate - please do not use shortened names/abbreviations
You can only refer yourself to us if you are over 18.
Is there a time or day of the week you prefer to be contacted on?

GP Details

Your Personal Information

Referral Information

Upon receipt of your referral, you will be contacted by the service to arrange your initial telephone assessment appointment.
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.