Self Referral Form

V2

Personal Details

You can find your NHS Number on prescriptions, including repeat prescriptions, or by asking your GP surgery. Failure to provide us with your correct NHS number may delay your access to treatment.
Numbers to be provided without spacing
Failure to provide an accurate contact number will delay your access to therapy
By confirming that Surrey IAPT can correspond with you via email, you are agreeing that Surrey IAPT can send you via email, where necessary, confidential personal information. Any personal information sent by us, will not be encrypted or sent in a locked file format. Therefore, Surrey IAPT cannot be held responsible for the security of your personal information transferred to you by email.

GP Details

You must be registered with a GP based in Surrey to access our service. If you are registered with a GP outside of Surrey your nearest IAPT service can be found at www.iapt.nhs.uk. Please note we are required to share information with your GP about your referral and treatment.
We must have the name of your GP, as we are required to share information with her/him about your referral and treatment.

Further Information

Referral Information

Mind Matters IAPT is not a crisis service If you feel concerned about risk you should see your GP as soon as possible.
In addition the following resources may be helpful;
• NHS Direct - Tel; 111 (anytime)
• The Samaritans - 116 123 (24 Hours support)
• Surrey and Borders Crisis Line - Tel; 0300 456 8342 SMS Text; 07717 989024 (weekends and evenings only)
We would advise that clients will be contacted by phone within 3 working days of our receiving this referral. Please note for confidentiality reasons our telephone number is withheld. A message will only be left if we have specific client consent.