Self Referral Form

Please complete all questions below - Your referral may not be processed until all the necessary information has been received.
If you need help completing this form, please email giving your name and telephone number - a staff member will then call you within a few days to help complete the form.

Your Personal Details



We use your phone number to call and text you about appointment information. We use your email address to contact you about your referral and also to seek feedback while you are engaging with our service or shortly afterwards. Therapists may also use your email address to contact you about appointments and send you resources. Please make sure you have written it accurately on the first page of this form.
People have told us that emails from us sometimes go into their spam folders. Please check these folders in your email account to ensure that you haven’t missed correspondence from us.
Information you share with us is confidential between you, our service and your GP. The only time we will break this confidentiality is if we are concerned that there is a serious risk of harm to you or someone else. We store information on our IT system. This is confidential, and cannot be accessed by anyone outside of our service. We do share anonymous information with NHS England and other statutory bodies that monitor our performance. This information may include details on the number of people we see, what type of treatment they receive, or if they recovered. This does not include your name, address, contact details etc.

Thank you for completing the above information, you will be contacted in due course.