Self Referral Form

Please note that in order to access our service you will need to be registered with a GP, or live, in the London Borough of Ealing. If you are unsure which IAPT service covers your area, please either use this link or arrange to speak to your GP.
If you work for the NHS or in a care setting in North West London (Hammersmith & Fulham, Hounslow, Ealing, Harrow, Brent, Kensington & Chelsea, Westminster, Hillingdon), you may also be eligible for our support via our priority service. For further information visit:
Any information that you share with the Ealing IAPT service will be treated in strict confidence in accordance with the provisions of the Data Protection Act 1998 and GDPR
We collect demographic information, such as religion and sexual orientation to ensure equity of service
* indicates required field

This referral form should only be used to refer yourself. If you are a Health Care Professional wishing to make a referral for a client, please use our HCP form


We will use your email address to confirm appointments and other communication relevant to your treatment.
If you do not have an email address or do not wish to provide one, please input the following:
We will use your mobile number to confirm appointments, send you questionnaires relevant to your treatment, and patient experience questionnaires.
We use an online appointment booking system, which allows you to choose and book your appointment. You will be sent a booking link via SMS (NB if you opt out of SMS communication, this feature will not be available to you and we will contact you to book your appointment manually)
Your chosen person will only be contacted in an emergency and will be able to act on your behalf if you are unable to communicate with us.
If yes, please provide their contact details below.


If you have answered yes, please provide the following information:
If yes, please provide the details of your carer below:




Ealing IAPT is a 9am – 5pm service and unable to provide urgent support. If you require urgent/crisis support, or if you are worried about immediate risk of harm to self or others, please call the 24/7 West London Helpline on 0800 328 4444 or the Samaritans on 116 123.
If you currently have a diagnosis of psychosis, schizophrenia, or a personality disorder, please make an appointment with your GP who will be able to refer you to the most appropriate service. Similarly, if you have had a recent admission to a psychiatric unit, please speak to your GP or care coordinator.
If we decide that we are not the most appropriate service for you, we may send your details to another service that may be more appropriate.
If we have concerns about your safety, we have a duty of care to liaise with appropriate healthcare professionals (GP, care co-ordinator, Psychiatrist, Nurse, etc) to ensure that necessary support is arranged.
In order to reduce wait for the service, we now work in partnership with Xyla Digital Therapies and Dr Julian. These services offer timely assessments and treatments. Do you consent to being contacted by either of these services if appropriate?