Self Referral Form

If you need immediate support please call your GP or go to your local Accident & Emergency department. For more information on accessing urgent help please see https://www.icope.nhs.uk/camden-islington/crisis-support/
Please provide as much information as possible to help us process your referral quickly. We offer a range of short-term, goal-focused psychological interventions for people who are looking to make changes in their lives. 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 Information

Please be aware that the information you share with us is kept confidential. However, if you share information concerning current or potential harm to yourself or another person, it is likely that we will need to inform other agencies to ensure that the right support is provided. We would always try to contact you first to discuss this.
We routinely share information with your GP and other NHS providers about your referral and treatment, which we may do either verbally or in writing. When we receive a referral we may look on Trust or GP notes to make sure we are the most suitable service for you. For more information about confidentiality and data sharing please see: https://www.icope.nhs.uk/camden-islington/helpful-resources/information-sharing-and-confidentiality/ or view our FAQs on the website. If you have concerns about information sharing please discuss them with us.

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 or who live in Camden and Islington, or staff working in NHS or social care in North Central London (Camden, Islington, Barnet, Enfield or Haringey). 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.

Emergency Contact

Please let us know if there is anyone you would like us to contact in the event of an emergency.
Please note we would only use this information in the event of an emergency

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. Please note, you will not receive any email confirmation after submitting this form but we will be in touch with you as soon as possible.