Patient Referral Form

v2
IAPT is not a crisis service.
If you need urgent support, please do not complete this form. Instead, please:
- Call the SLAM 24-hour mental health helpline on 0800 731 2864
- Call the Samaritans on 116 123

Please complete all questions below - Your referral may not be processed until all the necessary information has been received.

Your details

Reasons for referral

Service information

We use your phone number to call and text you about appointment information. We use your email address to contact you about your referral and also to seek feedback while you are engaging with our service or shortly afterwards. Therapists may also use your email address to contact you about appointments and send you resources. Please make sure you have written it accurately on the first page of this form.
People have told us that emails from us sometimes go into their spam folders. Please check these folders in your email account to ensure that you haven’t missed correspondence from us.
Information you share with us is confidential between you, our service and your GP. The only time we will break this confidentiality is if we are concerned that there is a serious risk of harm to you or someone else. We store information on our IT system. This is confidential, and cannot be accessed by anyone outside of our service. We do share anonymous information with NHS England and other statutory bodies that monitor our performance. This information may include details on the number of people we see, what type of treatment they receive, or if they recovered. This does not include your name, address, contact details etc.

After we have received your form...

Your details will be reviewed by one our team. We will then contact you by email or telephone about progressing your referral.
For all enquiries, please call 0203 228 1350