Self referral form

Is Steps2Wellbeing for me?

To refer yourself to Steps2Wellbeing please complete the form below.
We accept referrals from adults registered with a GP in Dorset and Southampton city. Please note this service is for adults aged OVER 18 ONLY.
We offer talking therapy for common mental health issues. So, if you are feeling down, worried or stressed we can help. Sometimes symptoms like the ones below can happen because of our mental health.
• Trouble concentrating
• Worrying and feeling stressed
• Feeling sick, dizzy, heart beating fast
• Changes in sleeping and eating
• Losing interest in things you enjoy
• Feeling bad about yourself
We also offer treatment for people whose mental health is affected by a long-term health condition like:
• Diabetes
• Stroke
• Chronic pain
I need emergency help
We are not a crisis service and are not the best service for you if you are very distressed, despairing, or suicidal.
If you need urgent help visit this website:
I don’t want anyone to know
We take confidentiality very seriously. The form is fully secure and all details you provide will be stored on our confidential system.
To get in touch with you and provide our services, we need to contact you. By completing this form, you agree to these terms and to be contacted via any available method.
We have a duty to share information with your GP and sometimes other healthcare providers to make sure that you are cared for. Further details can be found in our Treatment and Confidentiality Agreement. By completing this form, you are agreeing to the information and terms set out in the Treatment and Confidentiality Agreement. If you would like more information, you can talk to your Steps2Wellbring therapist about it.
You can read our Treatment and confidentiality agreement here -
Please note, fields marked with an asterisk * must be completed.
If you have not heard from Steps2Wellbeing within three working days of making a referral, please call us on 0800 484 0500 (Dorset) or 02380 272000 (Southampton).

Your Details

Note: Please complete at least one contact number

Further Details

Background Information