Self Referral Form

Complete this form to refer yourself for free and confidential treatment. You can also refer by phone on 0300 365 2000.
We’ll confirm your appointment details by email or send a booking link by text, usually within 5 working days.
We ask questions which help us identify areas where you are affected to ensure that we deliver a service that meets your needs.
If you need urgent mental health treatment, call NHS 111 for advice. If your life is in danger always dial 999.
This form takes about three minutes to complete. Questions marked with an asterisk are required.

Your GP will be made aware that you have been referred to Talking Therapies.

We keep the confidential information we send you by email to a minimum due to the risk of details being received by unintended recipients.
Emails from us may go to your spam folder.
We call from a withheld number. Rest assured, we prioritise your privacy on voicemails.

For video calls you will need a suitable device with a camera and internet connection and a confidential space at the time of your appointment.
We can offer an initial 40 minute appointment on weekdays, starting between 8am and 7pm.

If yes, please provide the following details of your probation officer so that we can obtain a risk assessment;

When you submit this form your details will be stored on our secure and confidential health record system. Search ‘privacy notice’ at to find out more about how we use your information.