Self Referral Form

Please note, NHS Coventry, Warwickshire and Solihull Talking Therapies Service is not a crisis service. If you are currently experiencing distressing thoughts and feel you may be at risk of harming yourself or someone else, please contact one of the following:
Your GP or out-of-hours service / NHS Direct on 111 / The Samaritans on 116 123, Mental Health Wellbeing Line on 0800 616171 (Coventry and Warwickshire only), the Mental Health Access Hub on 0300 200 0011 (Coventry and Warwickshire only), Birmingham and Solihull Urgent Mental Health Helpline on 0121 262 3555 or 0800 9159292 (Solihull only). In an emergency dial 999 or visit A&E.
Please answer each question as fully as possible.
By submitting this form you are consenting to us sharing information with your GP.

Personal Information

We will use your email to communicate important information about our service, such as appointment times and questionnaires to be completed prior to your appointments. We do not use your email address for any other purpose and never sell your information to any third party.
Please provide at least one contact number.

Reasons for referral

What happens next?

Thank you very much for completing these questions. If you have given permission for us to contact you via text message, then you will receive a booking link via text message within 7 working days. If you have not agreed to contact via text message, then we will make contact via either email or letter advising you how to book you initial appointment. If you do not hear from us within the next 14 days, or you need to contact us for any other reason then please call 02476 671 090.