Referral Form

If you need immediate support please call your GP or go to your local Accident & Emergency department.

Please provide as much information as possible so we can process your referral efficiently. If you are unsure if our service is the right service for you or if you have any problems completing this online form, you can call us to discuss this.

Title:*

First Name:*

Last Name:*

You can only refer yourself to us if you are over 18

Date of Birth:*

Gender:*

Address Line 1:*

Address Line 2:

Town:*

County:*

Postcode:*

Telephone Number:*

Can we leave voicemails on this number?:*

Yes

No

Other Number:

Can we leave voicemails on this number?:

Yes

No

Can we contact you via SMS?

Yes

No

Email:

By providing us with this information we will assume that you consent to be contacted in this way.

Preferred methods of communication:

Post

Phone

Email

SMS

Do you need an interpreter?:*

Yes

No

If yes, please specify your language:

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

Do you have a GP in Kingston?*

Yes

GP Practice:*

Please select here if you do not wish us to inform your GP:

Do not inform my GP

During the pandemic we are providing additional support for people experiencing distress or anxiety relating to COVID-19. We are also offering priority support to front-line staff and key workers.

If you are referring due to distress or anxiety related to COVID-19 please tick here:

Yes

Please indicate if you are any of the following:

Front-line staff working with patients experiencing COVID-19 (e.g. doctor, nurse, care assistant etc)

Key worker (e.g. pharmacist, teacher, social worker, police etc)

Vulnerable/shielding

We ask these questions to ensure that our service is being accessed by everyone and to ensure any specific requirements are met.

Ethnicity:*

Sexuality:*

Do you have any long term medical conditions?:

Do you have any specific needs you would like us to be aware of e.g. a disability?:

Are you pregnant or do you have any children under 1 or under 5?:

Pregnant

Children under 1

Children aged 1-5

Are you an ex-British Armed Forces member?:*

Have you received in the past, or are you currently receiving counselling, therapy or other mental health support elsewhere?:*

Yes

No

Unsure

If yes, please provide further details:

Please provide brief details of your problem or what you would like us to help you with:*

Would you prefer to have all of your contact with our service online if this is available? (this may include online therapy programmes, communication with your therapist online or video sessions):*

Yes

No

Maybe

Where did you hear about us?*

If other, please specify:

Thank you for taking the time to complete this form. We hope to be in touch with you within two working days.

Please be aware that if you report any immediate intention to harm yourself or commit a crime, it is likely that we would have to inform other agencies for your own welfare. We would always try to contact you first before making such a decision.

Please complete the captcha

Self Referral Form

Your Details

GP Details

COVID-19

Further Information