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, 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.