Self Referral Form

To refer yourself to Living Well Consortium’s online CBT service (cCBT), please fill in the form below. Within 30 minutes of this form being submitted, Silvercloud will email you to complete secondary questionnaires around your general wellbeing. These must be completed for your referral to be processed.
For more information on cCBT, please look on our website under Urgent Help and Referrals. If you are not looking to access cCBT, information on our other services can be found on the same page.
If you have any issues completing this form, please give us a call on 0121 663 1217 between 9 and 5pm, Monday to Thursday, or 9 and 4pm on Friday.
Please be aware that our service is not a crisis service. If you are feeling suicidal, please contact your GP for an emergency appointment, call the Birmingham Mind 24 hour line on 0121 262 3555 (freephone 0800 915 9292), the Samaritans on 116 123 or attend your local A&E.
This referral form is for assessment and access to SilverCloud Computerised Cognitive Behavioural Therapy (cCBT) only. This is considered by Living Well Consortium to be a treatment intervention in its own right. Whilst your referral for SilverCloud is active, you may not:
• Be on any assessment or treatment waiting list with Living Well Consortium
• Be currently accessing any other treatment with Living Well Consortium
• Have accessed any other treatment with Living Well Consortium within the last 3 months
If you complete this form whilst any of the above conditions apply, you may be contacted via telephone or email for clarification.

About You

Your Health

GP Details

Contact Details

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Next of Kin Details

How can we help?

(Please try to describe your thoughts, feelings, things that trouble you, and the impact this is having on your life in a few sentences.)