Please note that referrals can be made on behalf of someone else with their consent. Please ensure that the individual is fully aware that you are making the referral.
If you are a Health Care Professional wishing to make a referral for a client, please DO NOT use this Self Referral form. Please instead, email: to request a HCP Referral Form.
Fields marked with a * are required.

Personal Details

Please note, in an attempt to save the planet Hounslow IAPT are making every effort to go paperless. You will therefore receive correspondence via secure email. Should you have any difficulties with this, please indicate you prefer to receive letters by post.
If you do not have an email address, please input the following:
We are only able to accept referrals for those registered with a GP Practice in Hounslow.

Demographic information

NHS Worker

NB: In the interests of confidentiality, if you are employed by West London NHS Trust, we will forward your referral to Keeping Well to seek a service outside of this Trust to process your referral. For further information visit:

Carer / Support

If yes, please provide the details of your carer below:

Next of Kin Details

Further Information

We are a 9-5 service and are unable to provide urgent support. If you are in need of emergency help or if you are in a crisis, please call 0800 328 4444, call 999, or present to your local A&E so your treatment is not delayed.
We are an Adult ONLY service. If you are under 18 years of age, we will not be able to process your referral.
If you are under the age of 18 years, please ask your GP to make a referral to the CAMHS Service or you can make a self-referral to Hounslow Youth Counselling: Tel: 0208 568 1818 / email:
If you have a diagnosis of Psychosis/Schizophrenia, Bipolar Affective Disorder or Personality Disorder, or you have had a recent admission to a Psychiatric Unit or A&E, please ask your GP to make a referral to the relevant Mental Health service on your behalf. Likewise, if you suspect you have any of the above, please speak with your GP. This ensures you are referred to the relevant Mental Health service for you and will minimise any delay in your treatment.
If we decide that we are not the right service to offer you therapy, we may send your referral to another service that may be more appropriate for you.
If we have concerns about the safety of anyone accessing our service, we have a duty of care to liaise with appropriate health care professionals to ensure that the necessary support is arranged. For example contacting GP, Care co-ordinator, Psychiatrist or Psychologist.
In order to reduce your wait for the service, we now work in partnership with Xyla Digital Therapies. This service offers timely assessments and treatments.
The Department of Health monitors all IAPT Services, as well as other NHS services, to check quality standards are similar everywhere. The Health and Social Care Information Centre (HSCIC) is the organisation responsible for providing reports on service data to the Department of Health. They monitor how many people are referred to services, waiting times and recovery. In order for them to do this, we send summary reports of the work we do to our commissioners. This numerical data includes no information that could reveal an individual's identity and the information is stored securely. You can find out more at or, or by calling the HSCIS patient line on 0300 456 3531. Alternatively, you can discuss this with the clinician who assesses you.