Self Referral Form

You will be eligible for this service if you are registered with a GP in Kensington and Chelsea, or in the Queens Park and Paddington area of Westminster - if you do not fit this criteria find your local service at You can also access this service if you live work or study in our catchment area or work for the NHS in North West London and would like support from the service, in these cases you do not need to be registered with a GP in the area. Please indicate clearly on the referral form if you do not have a GP in the area and are referring because you live / work / study in Kensington and Chelsea or are an NHS employee in NW London.
This self-referral form is a way for you to access psychological support and advice from your local talking therapies service. This service is for people who are experiencing stress, worry or low mood or struggling to cope with everyday life due to emotional difficulties. If you have a history of serious mental health issues or drug and alcohol problems it is possible we are not the best service to help you and we suggest you go to your GP for advice.
We are not able to provide immediate support in an emergency. If you require immediate help please contact your GP, your local Accident & Emergency Department, or call the Urgent Advice Line on 0800 0234 650 open 24 hours.
Through completing this form you are consenting to have this information stored confidentially on a secure electronic system separate from your GP's system and for your GP to be informed of your contact with us.
If you are unable to complete this form for any reason or if you would prefer to complete this form on paper, or give your details over the phone, please call 0203 317 4200, or email
By providing these details you are giving consent for us to contact you regarding confidential information.

Personal Details

If you have selected No, please specify the language (including BSL), and we will organise an assessment with an interpreter (please note that we use professional interpreters and will not use family members/friends to interpret for you).
Please note that, whilst NHS email is secure, we cannot guarantee that your own email server will be so. Please only give us your email if you are happy for confidential information to be sent to your email address.

GP Details

Further Information

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

Referral Information