Self Referral Form

V2
Talking Therapies will contact you by your preferred method within 5 working days. If you do not hear from us within this time frame please call us on 0300 365 2000.
Fields marked with an asterisk * are required.

Personal Details

What are your preferred days and times to be contacted by one of our therapists for an initial telephone assessment?
If we are unable to contact you by phone or leave a message we will write to you.

GP Details

Demographic Information

Other Information

Please note - A telephone translator and interpreter service is available. Please indicate below if this is required and the language you would prefer to use. A translator will then be available when we telephone you.
If yes, please provide the following details of your probation officer so that we can obtain a risk assessment;

Referral Information

By completing this form and pressing submit you are agreeing to your details being stored on our secure, confidential system and to your data being shared with the Department of Health and other health care providers, this is for the purpose of research and audit. Please note the information shared will not identify you in any way.