Time To Talk Health Online Self-Referral Form

All information kept securely in accordance with the Data Protection Act and General Data Protection Regulation (GDPR).
Our qualified approachable team offer talking therapies to you alongside your healthcare team to achieve the outcomes you want. This form allows you to refer yourself to the service. If you have any problems completing it or have additional needs that you would like us to know about then please contact our admin team on the contact number below who will be very happy to help you complete your referral over the phone:
Time To Talk Health Admin Team - 01273 666480

Access Questions

Before going any further please answer the following 6 questions:
You cannot fill in this form on behalf of someone else. This form is not, however, the only way to access the service, people can call on the phone number above or can be referred via their GP.
We are an adult service and do not treat people under 18 years old. If you are under 18 and wish to access talking therapy please make an appointment with your GP to discuss the available options.
If this is not the case you can find your local talking therapy service by visiting the NHS Choices website at www.nhs.uk.
If you would like more information about this please call the number above.
If you would like more information about this please call in on the numbers given above.
If this is not the case please make contact again when you do have availability in the next fortnight.
If you answered “Yes” to all of the above please complete all fields below. If you've answered “No” to any of the above please do not continue with this form as we will not be able to accept your referral at this time.
After you submit this form our admin team will contact you by telephone within three working days to arrange an assessment with a member of our team. This assessment will take 45-60 minutes and will help us clarify your needs and determine whether this is the best service for you. PLEASE BE AWARE THAT WHEN WE CALL YOU OUR TELEPHONE NUMBER WILL SHOW AS “WITHHELD” ON YOUR PHONE.

Personal Details

If you would like to be contacted via email (regarding appointments and questionnaires only), please provide your email address. Please note, although we can guarantee the appropriate security of our nhs email system, during transfer over the Internet we cannot guarantee the security of the email, or be responsible for the security of any emails once sent or in the patient’s own email inbox.

Further Information

On receipt of your details we will contact you to make an appointment for assessment. If we're unable to meet your needs please be assured we'll advise you and let you know of suitable alternative help available.

If you need urgent help or support in a crisis

Time to Talk Health is not able to offer crisis/urgent support. If you need more immediate support please consider the following:
- Request an urgent appointment with your GP or your healthcare team
- Attend your local A&E department
- Contact the West Sussex Mental Health Line on 0800 0309 500 (24 hours)
- Contact the Samaritans on 116 123 (24 hours)
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