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 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.

Please complete the following fields. Even if you are already registered with us, it will help us to process your request more efficiently.

Title:*

First Name:*

Last Name:*

Please note – We are only able to accept self-referrals from people aged 16 or over.

Date of Birth:*

Gender:*

Address Line 1:*

Address Line 2:

Town/City:*

County:*

Postcode:*

Preferred method of contact:*

Preferred Phone Number:*

Preferred Phone Type:*

Is it ok to leave a voice message on your preferred number?:*

Yes

No

Do you consent to receiving text messages?:

Yes

No

Other Number:

Email Address:*

By giving us this information we are assuming that you consent to being contacted in this way.

Do you need easy read?

Yes

No

Easy Read - Information that is easier to read by using simpler words and pictures to help people understand.

GP Surgery:*

Nationality:*

Ethnicity:*

Do you require an interpreter?:*

Yes

No

Do you need a sign language interpreter?:*

Preferred Language?:*

If appropriate, please specify the dialect?:

Sexuality:*

Are you a carer for someone with physical or psychological difficulties?:*

Yes

No

If yes, adult or child?:

Adult

Child under 18

Do you have any long term medical conditions?:*

If yes, please specify:

Do you have any mobility needs?:*

Yes

No

Do you consider yourself to have a disability?:*

Are you an ex-British Armed Forces member?:*

Are you pregnant or do you have a child under two years old?:

Yes

No

Is your partner pregnant or have a child under two years old?:

Yes

No

Do you work for NSFT?:*

Yes

No

Have you ever been to the Wellbeing Service before?:

Yes

No

Can you tell us a little bit about what you would like some help with:*

Where did you hear about us?:

If Other, please specify:

Any other additional information:

Your referral may be passed to one of our partner organisations for treatment this organisation is Xyla Digital Therapies. To learn more about how we manage your information please see our privacy policy at https://www.wellbeingnands.co.uk/suffolk/privacy-policy/

Please complete the captcha

Self Referral Form

Personal Details

GP Details

Further Information