Self Referral Form

If you need immediate support please call your GP or go to your local Accident & Emergency department.
Please provide as much information as possible so we can process your referral efficiently. If you are unsure if our service is the right service for you or if you have any problems completing this online form, you can call us to discuss this.

Your Details

You can only refer yourself to us if you are over 18
By providing us with this information we will assume that you consent to be contacted in this way.

GP Details

We only see people with a GP in Camden or Islington. We ask for your GP details so we can contact them about your care if needed. We may check your NHS records held by your GP or other NHS Providers where we need further information to help us provide you with the best possible care.

Further Information

We ask these questions to ensure that our service is being accessed by everyone and to ensure any specific requirements are met.
Thank you for taking the time to complete this form. We hope to be in touch with you as soon as possible.
Please be aware that if you report any immediate intention to harm yourself or commit a crime, it is likely that we would have to inform other agencies for your own welfare. We would always try to contact you first before making such a decision. For information about confidentiality and data sharing please see: or view our FAQs on the website.