Complete our self-referral form

NAME*

EMAIL

TELEPHONE

POSTAL ADDRESS*

DATE OF BIRTH*

GP PRACTICE ADDRESS*

EMERGENCY CONTACT NAME*

EMERGENCY CONTACT PHONE NUMBER*

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.*

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.

ANY ADDITIONAL INFORMATION?