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 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.

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.
Please note – We are only able to accept self-referrals from people aged 16 or over.
By giving us this information we are assuming that you consent to being contacted in this way.
Easy Read - Information that is easier to read by using simpler words and pictures to help people understand.

GP Details

Further 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