Self Referral Form for Westminster

You will be eligible for this service if you live in Westminster and / or have a Westminster GP - if you do not fit these criteria please contact your local service.
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 030 3333 0000 or email your local service (
By providing these details you are giving us consent to contact to you regarding confidential information.
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