Sunderland Psychological Wellbeing Service Self Referral Form

Access Questions

Before going any further please answer the following 5 questions:
You cannot fill in this form on behalf of someone else. This form is not, however, the only way to access the service, people can call on the phone numbers listed above or can be referred via their GP.
We do not treat people who are still currently in secondary education. If you are in Year 11 or below and wish to access talking therapy please make an appointment with your GP to discuss the available options.
If this is not the case you can find your local talking therapy service by visiting the NHS Choices website at www.nhs.uk.
If you would like more information about this please call in on the numbers given above.
If this is not the case please make contact again when you do have availability in the next fortnight.
If you answered “Yes” to all of the above please complete all fields on the form below to access the Sunderland Psychological Wellbeing Service. If not, please do not continue with this form as we will not, unfortunately, be able to accept your referral at this time.
After you submit this form our admin team will contact you by telephone within three working days to arrange a telephone triage with a practitioner. This telephone triage will take approximately 30 minutes and will help us clarify your needs and determine whether this is the best service for you.
PLEASE BE AWARE THAT WHEN WE CALL YOU OUR TELEPHONE NUMBER WILL SHOW AS “NO CALLER ID” ON YOUR PHONE.

Your Details

GP Details

Further Information

Referral Information