Self Referral Form

This is not an emergency service. Your referral will be processed in the next few days. If you feel at immediate risk to yourself or others please call NHS 111.
Please use this form to refer yourself. We accept referrals from anyone over the age of 16 who is registered at a GP in the County Durham and Darlington area. Please note, registering with our service implies permission to communicate with your registered GP; if you would prefer us not to do this please contact us to make a referral via phone on 0191 333 3300 or, alternatively, submit the form below but then contact us using the ‘contact form’ on our ‘contact us’ page on our website to inform us of your preference not to have information shared with your GP.
Please note all calls from our service are from a withheld number.
We are unable to rearrange cancelled or missed initial assessment calls. However, you can re refer back into service using this form or by calling 0191 333 3300 choosing Option 1.
It is your responsibility to ensure the information provided is accurate in order for us to process the referral.
Please note, fields marked with an asterisk * must be completed.
If yes, please complete all of the below mandatory fields and email any assessments/documentation within 72 hours of your referral to: If we do not receive your assessment within 72 hours your referral will not be processed.
If no, we are extremely sorry we only accept self referrals or referrals from health care professionals on behalf of someone else. Please contact your GP for further advice and support.

1. Your Details

If No, we will send SMS text messages to the mobile number provided below as we need to be able to contact you via letter or text message to process your referral.

2. Contact Details

Please leave at least one contact number.

3. Further Details

Please note, in order to receive this service you must be registered with a GP in the County Durham and Darlington area.

4. Emergency Contact Details

If yes, please complete details below. If no, please skip to Further Details section.