Self-Referral Form

Is Talking Therapies the right option for you now?

I need emergency help
We are not a crisis service and not the best service for you if you are very distressed, despairing, or suicidal.
If you need urgent help, there is a freephone telephone line where you can speak to someone who will listen and determine how best to help; the Cornwall 24/7 NHS mental health response line (0800 038 5300) is there for support and advice.
You should dial 999 or go to the Accident and Emergency Department now for immediate help.
I need support for a diagnosed mental health condition
Talking Therapy is not for everyone, and we want to make sure you get the help and support you need. If you are looking for treatment for psychosis, schizophrenia, bi-polar disorder, eating disorders, historical sexual abuse, or complex emotional difficulties, please call Mental Health Connect on 0800 038 5300 for support and advice.

What’s the main reason for your referral?

We need this information so our therapist can explore with you the best course of treatment during the assessment appointment.
Reasons for referring yourself.
There are different options for treatment, which your therapist can explore with you during your assessment. Please visit (copy and paste in to a new window) for more information about these.

Your Details

(Please note if you are under 16 and seeking support, you should contact the Early Help Hub on

How can we contact you?

We like to keep in contact with you at every step of your treatment. This includes appointment arrangements, questionnaires about how you are feeling and your experience of your therapy. Please indicate below how we can contact you.
Please note, we use your email address, if you have one, to keep in contact with you and send questionnaires about how you are feeling before your initial appointment and throughout your treatment with us. If you do not wish to receive these by email, please email us at or call us on 01208 871905 to let us know.
Emails from our service may go straight into your junk mail or spam folder. The email address our questionnaires comes from is: please add this email address to your safe list and check your junk/spam folder for any confirmation emails from us.

Emergency contact

GP details

Information from this assessment and your future care is always shared with your GP so they are informed about any treatment you are receiving. To access the NHS Cornwall and the Isles of Scilly Talking Therapies service you need to be registered with a GP in Cornwall. If you are not registered with a Cornish GP, please contact the NHS Talking Therapy service in your GP area.

Further information

We ask the next set of questions to help us check we are doing our best to reach out to everyone in our community.
We support people with a wide range of needs so answering these questions will help us to understand how we can best support you.
Please give us information on any disabilities (physical or learning) and any long-term medical conditions. We offer a specific service for people diagnosed with the following long-term conditions - (diabetes, cardio-vascular disease, COPD and IBS). In addition, telling us about any other medical conditions, will help your therapist understand more about you.

What Happens Next?

Within 5 working days of receiving your referral, you will be contacted by a member of our admin team to arrange your initial telephone assessment appointment with one of our therapists. Once confirmed, your appointment details will be emailed or posted to you and will include further information about what to expect.
There may be times when we would need to discuss transferring your care with other services if we are not the appropriate service to meet your needs. If you do not hear from us after 5 days, please feel free to contact us on 01208 871905 or email

How we store your information

In taking your details, we recognise the importance of personal privacy and make sure all information about you is held securely in accordance with the Data Protection Act 2018 and UK General Data Protection Regulation (UK GDPR).
The information you provide on this form and during your care will be used to document, monitor and plan your treatment. We will share information with other health care professionals for the purpose of direct care to ensure continuity of care and that the treatment provided is appropriate to your needs.
For further information please copy this link into a new tab: