Self Referral Form for Harrow

In order to be eligible for our service, you must be registered with a Harrow GP (regardless of whether you live in Harrow or not). Please contact your local IAPT service if you do not have a Harrow GP.
This self-referral form is a way for you to access psychological support and advice from your local talking therapies service. The service is for people who are having emotional difficulties and are struggling to cope with everyday life. If you have a history of serious mental health issues or drug and alcohol problems it is possible we’re not best suited to help you and we suggest you go to your GP for advice.
We are not able to provide immediate support in an emergency. If you require immediate help please contact your GP, or your local Accident & Emergency Department, or call the Urgent Advice Line on 0800 0234 650 open 24 hours.
Through completing this form you are consenting to have this information stored confidentially on a secure electronic system separate from your GP’s system, and for your GP to be informed of your contact with us.
If you are unable to complete this form for any reason or if you would prefer to give these details over the phone please call or email your local service.
By providing these details you are giving us consent to contact to you regarding confidential information.
If you have selected No, please specify the language (including BSL), and we will organise an assessment with an interpreter (please note that we use professional interpreters and will not use family members/friends to interpret for you).
Please note that, whilst NHS email is secure, we cannot guarantee that your own email server will be so. Please only give us your email if you are happy for confidential information to be sent to your email address.

GP Details

Further Information

We ask these questions to ensure that our service is being accessed by everyone and to ensure any specific requirements are met.

Referral Information