Self Referral Form

We are best able to help you if your main issue is low mood, stress or anxiety difficulties. If you are experiencing more chronic and enduring mental health or substance misuse issues you could benefit from seeing your doctor (GP) before completing a self-referral form to our services to help you choose the most appropriate service for your needs.
If you are in need of immediate help because of a mental health crisis and feel unable to keep either yourself or someone else safe, please call 999.
You can contact the NHS Helpline on 111.
If you would prefer to use our interactive referral system, please visit our website on By using this option we can gather more information from you and identify the right person for you to talk to. There is plenty of opportunity for you to tell us in your own words how you are feeling and what you are hoping to get help with.

Personal Details

Please complete the following fields. Even if you are already registered with us, it will help us to process your request more efficiently.
By giving us this information we are assuming that you consent to being contacted in this way.

Emergency Contact Information

By providing this information it doesn’t act as consent to share information about your care with this person, it means in case of emergency they would be the person we would contact.

Doctor (GP) Details

Further Information

We are committed to improving the care we provide, and to do this, we want to hear from those who use our services. If you might want to help improve The Norfolk and Waveney Wellbeing Service, please express your consent to be contacted in the future by ticking the box below.
Your referral may be passed to one of our partner organisations for treatment these organisations are Xyla Digital Therapies and Dr Julian.
Please complete the captcha below. Use the circular arrows button to refresh the images if required.
To learn more about how we manage your information please see our privacy policy at