Self Referral Form

Self Referral Form:

You can access our services and support by calling 01642 257020 or by completing our online support enquiry form.

We also accept referrals from GPs and other professionals. If you are a professional wishing to refer someone, please complete this form.

We can accept enquiries made by parents or the legal guardian of children. If you are a parent or legal guardian wishing to refer your child, please complete this form.

If you want to complete a self-referral, please answer the following questions:

Are you in crisis now?

     

We believe you need more urgent support and you can access immediate help here:

Urgent Help

Are you completing this form for yourself?

     

You cannot fill in this form on behalf of someone else.

If you are a professional wishing to refer a patient, please complete this form.

If you are a parent or legal guardian/representative wishing to refer a child, young person or someone in your care, please complete this form.

Are you aged 18 or over?

     

If you are aged 18 or under and wish to access our services please ask your parents or legal guardian to complete this form.

Alternatively, you can ask your GP to refer you using this form.

Online Self Referral Form

By completing and submitting this form you are agreeing your information can be stored on our confidential database. Please take a look at our Privacy Policy for more information.

* = Mandatory Fields

Personal Details

Additional Information


Consent to process your enquiry

To process your enquiry we need to ensure that you are aware of how we look after your information.

The main points are covered in our Privacy Policy which can be found here.

If you have any questions about how we manage your information, you can discuss these with us at any time.

Further Information can be found in the link to ‘I accept terms and conditions’

What Happens Next

After you submit this form our friendly professional team will contact you to discuss the next steps.

This will help us clarify your needs and determine how we can best help you.

If you’ve asked for us to call you then please be aware that our telephone number may display as no caller ID on your phone.