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

If 'Counselling', please complete the following three fields:

Referrer details (If not child or young person)

Permission to Contact

For more information regarding storage and use of data please visit our website for our privacy notice or ask for a copy when speaking to our staff.