Self Referral Form

Please answer each question as fully as possible.
By submitting this form you are consenting to us sharing information with your GP.

Personal Information

You must be over 16 to access this service, if under 16 please speak to your GP.
(Please only provide if you give permission for us to email information about your care and any online forms that you may require as part of your treatment)
Please provide us with at least one contact number.

Reasons for referral

Please note, Coventry, Warwickshire and Solihull Healthy Mind Service (IAPT) 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 Matters 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.

What happens next?

Thank you very much for completing these questions. We will contact you once we have reviewed this form.