Self Referral Form

Please read before completing this form

Talking Mental Health Derbyshire is available to people over the age of 16 years who are registered with a Derbyshire or Derby city GP practice. If you are not a Derbyshire patient, you can search for your local IAPT service here: Your GP can also signpost you to a service relevant to your needs if you are not with a Derbyshire practice, or if you are under 16 years of age.
Please be aware that we are not crisis service or an urgent care provider. Please do not complete this form if you require help in a mental health crisis. If you are worried about risk of harm to yourself or anyone else, please speak to your GP or the NHS 111 service if your GP is not available. Additionally, you can contact the following services for support:
Derbyshire Mental Health Helpline: 0800 028 0077
Samaritans: 116 123
SaneLine: 0300 304 7000

About You

Please fill in all the information on this form as completely and as accurately as possible, only skipping the questions which you feel are not relevant to you. Any fields marked with an asterisk (*) require a response.

Your GP

Please provide us with the name of your registered doctor and the GP surgery you are registered with.

Additional Information & Accessibility

Your Next-of-Kin

If you can, please provide us with the information for an emergency contact. Please be aware that we will only contact this person in urgent circumstances.

Your Treatment

Next Steps

Once you have pressed the ‘Submit’ button, your information will be transferred to us securely and our administration team will complete the registration process. You will then be offered a telephone assessment appointment either by letter, telephone or online booking (link by text message). Depending on demand for the service, this offer of an appointment may take up to 10 working days to arrive.
At your assessment, you will have the chance to discuss your reasons for referring to our service and to find out more about what our service can do to support you.
If it is felt that our service is unable to offer you treatment at this time, we will endeavour to offer signposting to more suitable avenues of support.
Talking Mental Health Derbyshire is a partnership of several organisations: Derbyshire Healthcare NHS Foundation Trust, Derwent Rural Counselling Service, IESO, Relate and Xyla Digital Therapies. To help reduce the wait for our service, your referral for assessment may be passed to our digital therapy partner organisation Xyla. If you would prefer for your information not to be passed to Xyla please telephone 0300 123 0542 and advise our administration team.
For further detail about what information and data we collect and share please see: