Self Referral Form

If you feel that your mood is deteriorating, please contact your own GP. The Cumbria Health On Call team (CHOC) are also available out of hours on 111. The Samaritans are available 24 hours a day on 116 123.

Personal Details

If you answer No please ensure an email address is entered so we have an alternate written communication method.
Should we need to contact you by phone this would be within working hours (this will show up as a withheld number), please let us know which number is best to reach you on during the day. If this method of communication is not suitable please let us know.

GP Details

First Step sees Adults who are registered with GP Practices in Cumbria only, if you are registered with a practice outside Cumbria please contact you GP or NHS Choices (www.nhs.uk) for details of similar services in your area.

Further Information

If you feel that your mood is deteriorating, please contact your own GP. The Cumbria Health On Call team (CHOC) are also available out of hours on 111. The Samaritans are available 24 hours a day on 116 123.
I consent to you contacting the relevant GP or other services for further information if required in line with NHS Confidentiality agreements. I am aware information will be stored on a database.
Once the form has been submitted online please allow 3 working days then ring 0300 123 9122 during normal working hours to book a telephone assessment appointment. Failure to contact the service within 7 days of day of submission will result in this questionnaire becoming invalid.
Please note that referrals are usually reviewed by a clinician within two working days (Monday-Friday)