Complete our self-referral form

Name (or if you are seeking services for a child please enter the child's name)*

Surname *

Email

Phone

Street address*

City*

Region*

Postcode*

GP & Practice address*

GP City*

GP Region*

GP Postcode*

Date of Birth*

Please Select Your Service* Neurodevelopmental Assessment (Autism and/or ADHD)Clinical Psychology (talking therapies & EMDR)Psychiatry (medication review)Other (Occupational Therapy, Educational Psychology, Speech & Language Therapist, Dietician)

Reason for seeking support – please briefly outline the main difficulties/symptoms you are experiencing – this could be with thoughts, emotions, memories, behaviours*

How long have you been experiencing these types of difficulties?*

Have you have had any treatment before now? If so please describe what this was. Do you have any diagnosed mental health difficulties? If so, tell us who gave you this diagnosis*

Have you seen your GP about your difficulties?*

Please let us know if you are currently taking any medications, if you have any physical health problems and if you have any allergies.*

IMPORTANT: additional information required! Please describe any hospitalisations, history of deliberate self-harm, suicide attempts, addictions, psychotic episodes, any previous or current input from psychiatry or community mental health services and previous prescriptions for psychiatric medications. Please not that if you do not disclose these incidences it may result in your treatment being disrupted or terminated.

Emergency Contact Name*

Emergency Contact Phone Number*

I would like to use an insurance policy to cover the cost of my appointments (tick box).* YesNo
Name of insurance provider:.*
*please note we will require your insurance details and and authorisation code prior to any appointments taking place.