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
Title:
Please Select A Value...
Dr
Miss
Mr
Mrs
Ms
Mx
Prof
Rev
First name:*
Last name:*
Date of birth:*
Gender:*
Female - Including Trans Woman
Male - Including Trans Man
Non-Binary
Prefer not to disclose
Is your gender the same as at birth?:*
Yes
No
To use this service, you must live in or be registered with a GP in the London Borough of Ealing.
Address Line 1:*
Town:*
County:*
Postcode:*
GP Surgery you are registered with:*
NHS number:
How we can help
What is the main difficulty you would like support with?:*
Please Select A Value...
Low Mood/Depression
Worry/Anxiety
Stress
Panic
Specific Fears e.g. heights, social situations
Other
If other, please specify:
Do you have a disability?*
Yes
No
Do not wish to disclose
Are you pregnant or a parent of a child under the age of 1?:*
Yes
No
Communication
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.
Email:*
Mobile:*
Alternative contact details:
Can we leave a voice message on the mobile number?:*
Yes
No
Can we send SMS to this mobile number?:*
Yes
No
Additional needs
We can support people with visual and hearing difficulties / disabilities. We can also help people with language barriers.
Do you require communication in a specific format?:*
Yes
No
If yes, please describe your requirements:
Do you require an interpreter or a translator?:*
Yes
No
If yes, what language?:
Last few questions
What is your ethnicity?:*
Please Select A Value...
Asian or Asian British - Afghani
Asian or Asian British - Bangladeshi
Asian or Asian British - Indian
Asian or Asian British - Japanese
Asian or Asian British - Pakistani
Asian or Asian British - Sri-Lankan
Asian or Asian British - Filipino
Asian or Asian British - Vietnamese
Asian or Asian British - Any other Asian background
Black or Black British - African
Black or Black British - Caribbean
Black or Black British - Somalian
Black or Black British - Any other Black/African/Caribbean background
Mixed - White and Asian
Mixed - White and Black African
Mixed - White and Black Caribbean
Mixed - Any Other Mixed or Multiple Ethnic Background
White - Eastern European
White - English, Welsh, Scottish, Northern Irish or British
White - Gypsy or Irish Traveller
White - Irish
White - Roma
White - Any other White background
Other Ethnic Groups - Arab/Any other Middle Eastern background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Iranian
Other Ethnic Groups - Iraqi
Other Ethnic Groups - Polish
Other Ethnic Groups - South American
Other Ethnic Groups - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
What is your religion?:*
Please Select A Value...
Agnostic
Baha'i
Buddhist
Christian
Hindu
Jain
Jewish
Muslim
Pagan
Sikh
Zoroastrian
Any other religion
Not religious/ no religion
Patient does not wish to state
Patient Religion Unknown (Patient not asked)
What is your sexual orientation?:*
Please Select A Value...
Bisexual
Heterosexual
Lesbian or gay
Other
Unknown
Does not wish to state
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