Referral Form

V2

To refer yourself to our service simply fill in the form below to give us your details, please note we can only accept referrals from people registered with a Lambeth GP surgery. Once you’ve completed and submitted the form, call us on 020 3228 6747 between 9am – 5pm Monday to Friday to arrange your first assessment appointment.

Title

First Name

Last/Family Name

Date of Birth

Gender

Male

Female

Other

Address Line 1

Address Line 2

Town/City

Postcode

Permission to send letters to your home address

Yes

No

Mobile Number

Permission to contact by text

Yes

No

Permission to leave voicemail

Yes

No

Other Number

Permission to leave voicemail

Yes

No

E-mail

Permission to send email?

Yes

No

Do you need an interpreter?

Yes

No

If yes, please specify your language

Ethnicity

Sexuality

Are you pregnant or do you have a child under 12 months old?

Yes

No

GP Practice

Permission to inform GP of referral and outcome of referral

Yes

No

Use this space to briefly tell us about the main problem that led to you contacting us.

We offer help for anxiety and depression using our online ‘Silvercloud’ programme. This is a series of 6-8 weekly modules that you work through with support from one of our clinicians. We can offer quick access to this and it’s effective and flexible, as you can complete your sessions at any time, day or night

You can find out more information in the 'Treatment types' section of our website.

If you are interested in this option, please indicated it here and let us know when you call

I would be interested in Silvercloud

I would not be interested in Silvercloud

Use this space for any specific requests, e.g. about how we contact you, or any disabilities we should be aware of.

Once you’ve submitted the form, please allow at least twenty minutes for your form to be processed then simply call us on 020 3228 6747 between 9am – 5pm Monday to Friday to arrange your first assessment appointment.

Please complete the captcha

Lambeth Self Referral Form

Personal Details

GP Details

Further Information