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, fields marked with an asterisk * must be completed.

Your Details

Contact Details

Please leave at least one contact number.

Further Details

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