Plymouth Options Self-Referral Form

Plymouth Options offer treatment for people experiencing common mental health difficulties.
Please complete the referral form in as much detail as possible. The form can take up to 20 minutes to complete.
Your referral will be processed and we will contact you in due course on the treatment most suited to your difficulties. Please note that the initial treatment option can often be a course or online-therapy, particularly for people using our service for the first time.

Please Note

Plymouth Options is not an acute service so is not suitable for people;
- Who are a high risk to themselves or others, such as current risk of suicide or serious self-harm
- Already undertaking another form of psychological therapy
- Who are using substances such as alcohol or recreational drugs to self-medicate
- Who have current severe or enduring mental health needs and as such require specialist services
- Plymouth Options is not an emergency service. If there is a life-threatening situation you need to contact emergency services on 999 or present at the nearest A&E department. For all non-emergency medical/mental health interventions please contact your GP during normal working hours. You can also phone NHS 111 for urgent medical problems who are open 24 hours, 7 days per week. Additionally you can contact the Samaritans to talk about mental health issues on: 116123

Personal Details

GP Details

We may share appropriate clinical information with your GP

Reason for Referral

Please give as much detail as possible


Please complete each question in the questionnaires below to help us identify symptoms of low mood and/or anxiety:


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

If you answered 'several days', ‘more than half the days’ or ‘nearly every day’ to Question 9 above, please complete the following questions:


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.

Further Information

Where did you hear about us?

What Happens Next

Thank you for completing this referral form.
One of our clinicians will review your information and contact you by your preferred method with the treatment options available. If we need any further details or clarity on the information you have provided then we may contact you to arrange a brief triage assessment call.
The initial treatment option offered may be either one of our psycho-educational Cognitive Behavioural Therapy (CBT) courses or our online CBT program, as detailed below:
Psycho-educational courses
- Psycho-educational courses provide a good introduction to CBT and are taught in a classroom environment. They are designed to help you understand your difficulties and equip you with tools to manage your symptoms. The full list of our courses can be viewed on our website.
Online CBT programs
- Online CBT programs are designed to help with problems of anxiety, stress or depression. We also offer specific online programs for patients suffering with long term physical health conditions (e.g. COPD, Chronic pain), as well as specifically designed programs for students. The full list of online programs can be viewed on our website.
Many people find the courses are enough to help them through their current difficulties and don't require any further support. If at the end of the course you do require further help then we can review this at that time.