Self-referral Questionnaire

steps2change provides talking therapies for people experiencing problems with anxiety, depression, stress and offers help with issues like bereavement or the impact of a traumatic event.
Please note that steps2change Lincolnshire is for mild to moderate mental health problems and cannot provide an urgent/emergency service. If you feel you are at risk of harming yourself, or someone else please contact your GP, attend the nearest A&E department or call 999 as a matter of urgency.

Personal Details

GP Details

Further Information

Referral Information

Please give brief details of why you wish to access steps2change. Can you describe the way that your problem impacts on your life, how long for have been experiencing this problem and any other information you feel we need to know?