Self Referral Form

IAPT is not a crisis service.
If you need urgent support, please do not complete this form. If you feel unable to keep yourself (or others) safe and need immediate help, CALL 999 or go to the nearest hospital A&E Department.
Alternatively, please call:
- Oxleas Urgent Advice Line on 0800 330 8590
- The Samaritans on 116 123 (available 24 hours, free to call from landlines and mobiles)
- The NHS non-emergency service on 111 who can advise you if you are unsure of what to do
Please complete all questions below - Your referral may not be processed until all the necessary information has been received.



Over the last 2 weeks, how often have you been bothered by any of the following problems?


Over the last 2 weeks, have you been bothered by any of the following problems?

Work & Social Adjustment

People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. To rate your problems look at each section and determine on the scale provided how much your problem impairs your ability to carry out the activity.

Phobia Scales

Choose a number from the scale below to show how much you would avoid each of the situations or objects.





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.


People usually come to our service to be helped with depression/ low mood or different types of anxiety. If you feel that your main problem is depression, please continue with question 1. If you feel that the main problem is a type of anxiety, please continue with question 2.
If you are unsure, please choose the emotion that upsets you the most.
Please choose the option that is most relevant to you and has the strongest impact on your day to day mood and behaviour.



This section will ask a series of questions that you might find difficult to answer, or you may feel are not applicable. Please could you answer as honestly as possible, to help us ensure that you receive the correct level of support.
If you need urgent help, please refer to the contact details at the top of the form.

CCBT is made up of a package of online mental health treatment programmes, mostly based on CBT, which help people to overcome common mental health problems
Usage is overseen by a supporter who;
- Monitor and review client progress.
- Provides feedback, guidance and encouragement, via regular written/phone reviews.
Thank you for completing the above information. This information will be uploaded onto our system and your assessment will be discussed in the next case management meeting where the most suitable treatment will be decided in line with recommended NICE guidance. If you are unsuitable for the service, we will contact you and inform you of this decision.