Self Referral Form

To refer yourself to our service simply fill in the form, let us know when you are available and we will send you an appointment.
Please be aware that our service is not a crisis service and if you are in a suicidal crisis, please contact your GP for an emergency appointment, call the Samaritans on 116 123 or attend your local A&E.

Personal Details

GP Details

Please note we always share information about risk with GPs. Even if you tick no here, any risk concerns will be shared with your GP.

How did you find us?

What is the problem?

If you are looking for a different kind of help, such as with help with housing or debt problems, please look at our resource page on our website.

Extra Information

Booking Your Appointment

The next step is we will call you for a telephone assessment, which will take about 20-30 minutes, to find out more about your difficulties and discuss next steps.
We will text you a time for this phone call. This will usually be within the next week, and assessments are available Monday - Friday, between 9.15 and 4pm.
Please specify below what days and times you are available for this call in the next week (or suggest other days if more convenient) e.g. Tuesday 10-11, Friday 9-3.30pm, or 'Monday' or 'anytime'. Please offer as many times as you can.
(If you would prefer to call us to arrange this, please call us on 0203 228 6747).
We will then text you an appointment time as soon as possible. Please check your phone daily.

Are you interested in computerised CBT?

We offer a digital programme based on CBT principles aimed at helping you to reduce symptoms of depression, anxiety or stress. You can log in at any time and will have weekly reviews with a therapist.
Thank you for contacting us. We look forwards to speaking with you. You will next hear from us via text to tell you about your appointment.
We anonymously share data from our service with NHS England and other statutory bodies that monitor our performance. This information may include number of people we see, what type of treatment they receive, or if they recovered. This does not include personally identifying information such as your name, address, contact details, etc. If you wish to opt out of NHS data sharing please copy and paste the following link to a new web browser