Self Referral Form

Complete this form for free support from NHS Ealing Talking Therapies.
It takes around four minutes.
If you need urgent help, please call the 24-hour West London Helpline on 0800 328 4444.
Fields marked with an asterisk * are required.

Your details

To use this service, you must live in or be registered with a GP in the London Borough of Ealing.

How we can help


We mainly contact patients by email and on their mobile. The booking link for appointments will be sent via SMS text. If you don’t have an email address or mobile number, please provide details of another way of reaching you.

Additional needs

We can support people with visual and hearing difficulties / disabilities. We can also help people with language barriers.

Last few questions