Self Referral Form

We are not a crisis service. If you need immediate help to keep yourself or others safe please call NHS 111 and press option 2, your GP, or go to your local Accident & Emergency department. If you feel yourself or others are at imminent risk of physical harm please call 999.

Child or Young Person Details

GP Details

Language Preferences

Information about your referral

Referrer details (If not child or young person)

Permission to Contact