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 work for the NHS and would like support from the service, if you are an NHS staff member you do not need to be registered with a GP in the area. Please indicate clearly on the referral form if you are an NHS staff member.
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.
To meet the challenge of Covid-19 we have temporarily changed the way we work to provide support to people who are self isolating or anxious about the virus as well as continuing to provide support for people experiencing stress, worry or low mood. We are also offering support to NHS staff affected by Covid-19. We are offering brief focused support by telephone, video call or online treatments.
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