Health Care Professional Referral

Please note that referrals can be made on behalf of someone else with their consent. Please ensure that the individual is fully aware that you are making the referral.
Fields marked with a * are required.

Referrer Details

GP Details

We are only able to accept referrals for those registered with a GP Practice in Hounslow.

Patient Details

Please note, in an attempt to save the planet Hounslow IAPT are making every effort to go paperless. They will therefore receive correspondence via secure email. Should they have any difficulties with this, please indicate you prefer to receive letters by post.

Patient Demographic Information

Next of Kin Details

Referral Information – Risk

Risk of Harm To Self (e.g. suicidal ideation, suicide attempts; self-harm; self-neglect)
Risk of Harm From Others (e.g. domestic violence, bullying)
Risk of Harm To Others (e.g. violence, aggression, risk to children)
HOUNSLOW IAPT IS NOT AN EMERGENCY SERVICE. If the patient is at active / current risk of harm to self, to others or from others, please refer the patient to West London Single Point of Access

Referral Information – Mental Health


NHS Worker

NB: In the interests of confidentiality, if they are employed by West London NHS Trust, we will forward the referral to Keeping Well to seek a service outside of this Trust to process your referral. For further information visit:

Carer / Support

If yes, please provide the details of the carer below: