Referral Form

We can help when life gets too tough.

If you are 17+ and registered with a Surrey GP, complete our self-referral form below and we will be in touch within a day. Or you can ask your GP to refer you.

Our NHS service is free, confidential and available throughout Surrey.

Title*

First Name*

Last Name*

Email Address

Date of Birth*

Please note: Clients must be 17 or over to use this service. If you are under 17, please see your GP or call us on 01483 906392 for advice.

Address Line 1*

Address Line 2

Town/City

County

Postcode*

Please leave at least one contact number.

Home Number

Can we leave a message on this number?

Yes

No

Mobile Number

Can we leave a message on this number?

Yes

No

Can we contact you via SMS?

Yes

No

Gender*

Are you pregnant / have given birth in the past year?*

Yes

No

Are you registered with a GP in Surrey?*

Yes

No

Name and address of your GP*

Your NHS number (if known)

If you are interested in either of these particular treatments please tick:

Online Treatment?

Workshops and Courses?

How did you hear of us?*

We would like to get in touch with you in order to assist you. We will not share your personal information with any third parties without your consent. Please select how you prefer to be contacted.*

Telephone

SMS

Email

Do you have any special communication requirements?

Yes

No

If yes, what support would be most helpful?

On submitting your form, you will receive a confirmation email explaining what will happen next.

We are not a crisis service and our service only operates Monday to Friday. For crisis support, please contact the Mental Health Crisis Line on 0300 456 8342, the Samaritans on 116 123 or your GP. You could also visit a local 'safe haven' for support (Find your local safe haven: https://www.sabp.nhs.uk/our-services/mental-health/safe-havens). For immediate support if you cannot keep yourself safe call 999 or go to A&E.

Please complete the captcha

Talk to us, self-referral

Can you keep yourself safe?