Self Referral Form

Kingston iCope offers short term psychological therapies for adults (18+) with anxiety and depression who are ready and able to work on their difficulties. For information on iCope therapies, visit our website: www.icope.nhs.uk/kingston/
If you are unsure if our service is appropriate, or if you have any problems completing this online form, please contact us at kingston.icope@candi.nhs.uk 0203 317 7850
Please provide as much information as you can. This will help us to decide if our service will be suitable for you.

Your details

Next Of Kin/Emergency contact details

GP details

We ask for your GP details so we can share basic information and contact them about your care if needed. Where possible we will discuss this with you first. We can only see people with a GP in Kingston.

More details about you

We ask the following questions to help us ensure that our service is inclusive for everyone.
If you do not speak English, please give us details of someone you trust who we can contact to book appointments.