Here For You (Essex) Self-Referral Form

What do we offer?

Welcome to the Here for You self-referral form. We appreciate how difficult it can be to reach out for help. By submitting this form, your information will be registered on our secure and confidential clinical record system. A member of the administration team will then contact you to arrange an appointment. We aim to acknowledge receipt of your referral within 3 working days and offer you an initial assessment appointment within 5 working days of your referral.
In order to submit the form you must complete the mandatory fields (marked with an *). All other information is optional and not completing these fields will not disadvantage your care in anyway. If needed, at your initial meeting with a member of the team, we may ask for additional relevant information.
If you are wanting to complete a referral on behalf of a colleague or team member, we ask that you please contact that individual and complete this form together. It is important that the person referred consents to the referral and is fully aware of all the information submitted. If you are a Manager or colleague looking for advice on how to support another member of staff please e-mail us at
As stated above, we store clinical records on a secure, password-protected database. Please tick to confirm that you understand these confidential notes will be kept as part of your care with our team.
As an NHS service, we are also required to submit anonymised data from these records to NHS Digital. You will not be identifiable from these data submissions.
Please note that you can change your mind regarding this consent at any time by talking to your clinician or by emailing the service.

How Can we Help?

Please select your primary reason for contacting us. We have listed some of the reasons people contact us below, if none of these fit for you, please use the "other" option and describe this in the box below. Please also add any further details you feel it would be important for us to know in the free-text box.

About You

Please note that the following fields are not mandatory. We collect this information because it allows us to monitor how effective we are being in terms of accessibility and inclusivity. We compare the information we gather with the known sociodemographics of staff across the region to inform our service developments and improvements.
How would you describe the following?

Contact Details

Emergency Contact Details

Registered GP Details

We will not routinely contact your GP unless you ask us to do so. We collect this information for circumstances where we have a duty of care to contact your GP, for example if were concerned about your safety. Please also be aware that, if we were to make an onward referral to another NHS service, it is highly likely that they will automatically contact your GP. Please discuss any concerns regarding this with a Here for You clinician, otherwise we will assume that you consent to this process.
Please note: whether or not you choose to provide your GP details will not impact on how we respond to your referral.

Your Workplace

Here for You offers support to individuals and teams across Essex and Hertfordshire. It is helpful for us to know who is accessing our service and from which teams. We also have a duty to report group data (no individual is identifiable from this) to NHS England as part of the commissioning process. Sharing this information will not impact on the care you receive and we will not contact or share any information with your employer, team or manager.

Your Availability

We will try to be as flexible as possible with our appointment times. Please let us know times when you would NOT be available to speak to one of our clinicians and will do our best to avoid offering appointments at these times. Please note that if you have very limited availability this may increase the time you wait for an initial appointment with us.

Permission to Contact for Feedback

We often contact people for feedback on their experience of our service. We do this to understand how the service can be improved in the future. This could include for the purposes of service evaluations or research. Please let us know if you consent to us contacting you after you have been discharged from our team.
Please note that you can change your mind regarding this consent at any time by talking to your clinician or by emailing the service.

My Information

How will this information be used?
The information you share with us is confidential and will not be shared with others without your permission except under circumstances where there is a serious cause for concern about your safety, the safety of others or if a British court orders the release of your records. Anyone who receives information about your care is also under a legal duty to keep it confidential.
If we do have significant concerns about your safety, and you have provided your GP details we will share this with your GP or relevant Emergency Services so that they can help you to obtain the support you need. We would always try to discuss this with you first.
We do not share any of the information you provide with your work colleagues or managers.
How do you store my information?
We keep your information on a dedicated specialist computer system stored on a secure server (iaptus). Your information cannot be accessed by anyone who is not involved in your care.
All data collected is subject to the strict rules of confidentiality, laid down by Acts of Parliament, including the Data Protection Act 1998, the Health and Social Care Act 2001, the European Union’s General Data Protection Regulation (GDPR), and the NHS Care Record Guarantee.
Please note: We are not a crisis service and this form should not be used for emergency support. At a time of crisis please:
Call 111 and select option 2 if you are feeling unsafe, unable to cope or are thinking about harming yourself or another person.
Call 999 or attend your local Accident & Emergency (A&E) department for immediate support in an emergency situation, including if you or another person are at risk of imminent harm.
Call the Samaritans on 116 123 or text SHOUT to 85258 if you are looking to speak with someone supportive in this moment.