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 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.
Please enter a telephone number starting with 07 and containing no spaces

Emergency Contact

GP Details

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.
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.