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.
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 you in touch with our services, we need to contact you. By completing this form, you agree to these terms and to be contacted via any available method.
You can read our page on confidentiality here:
Please note, fields marked with an asterisk * must be completed.

Your Details

Note: Please complete at least one contact number

Further Details

Background Information