Self Referral Form

Talking Therapies will contact you by email 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

We can only accept referrals from adults aged 17+
Although we limit the amount of patient identifiable information we send via email, please note personal email addresses such as Hotmail, Gmail etc. are regarded as non-secure.

First Appointment

Please note for video consultations you will need a device with a camera function, internet connectivity and confidential space at the time of your appointment.

GP Details

Please note your GP will be made aware that you have entered the Talking Therapies service.

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, your details will be stored on our secure confidential system. To find out more about how we use your information please visit the Berkshire Healthcare website to see our Privacy Notice at: