Self Referral Form

Please complete this form to refer yourself to our Hub team. We will meet with you, talk together about what’s been going on, and get you access to the right psychological support as fast as possible.

Personal Details

Please provide us your email address if you have one in order for us to send you quicker communications.

GP details

Further details

Employment

Please select from one of the 4 options below you work for (we will keep your contact with us completely confidential from your Trust / Sector unless we have jointly agreed with you to share information for the purposes of accessing fast-tracked local support, or to support you in the case of an identified risk of harm)*

Consent

The NHS regularly takes part in research on how to improve the experience of patients and the effectiveness of treatment. Do you consent for your anonymised data to be used for research to help us better understand the impact of COVID 19? (Please note: we will not be able to remove your data once you give consent, as it will be fully anonymised)
Would you be happy for our researchers to contact you regarding opportunities to take part in further research? You can withdraw your consent at any time. If one of our researchers contacts you, you will be asked for your consent again before taking part in research

Wellbeing / Covid-19

It will help us to provide you with the best service and to understand the need for mental health support across services if you could complete these additional questions.

Your Availability

Please tick the best days and times for us to offer you an appointment over the next couple of weeks. We have limited evening slots available, so to keep your waiting time to a minimum please only tick these if there is no alternative week-day time.