Welcome to the self referral form. Please complete the form, ensuring you include the name of your GP. You will be contacted (via email) once the form has been received. If you would prefer to make contact via email instead of via the form, please email agraycbt@protonmail.com By submitting this self-referral form, you agree and consent to be contacted regarding your request, and you are confirming you agree to our Privacy Statement, which can be found on our website, and to your personal data, as provided by you, being collected, used, disclosed and/or retained as per our Privacy Statement.