Referral form for clinicians and other referrers

Referral form for others/GP referrals

Please use this form if you are referring an individual on behalf of a GP, healthcare professional, organisation, or as a family member/carer.

We are unable to accept referrals via email for confidentiality reasons.

Therapy Process

The initial assessment is conducted by a qualified therapist and lasts approximately one hour. It will explore your current difficulties and your goals for therapy.

Following this, the therapist will recommend the most appropriate next steps and provide an indication of the likely length of support required. This may range from short-term work to longer-term therapy, depending on your needs.

If appropriate, therapy will be arranged after assessment. However, there may be a waiting period of up to 3 months before allocation, depending on demand and service capacity.

Important Information

We currently accept referrals from individuals based in the UK only
We are not an emergency/urgent care service
There maybe up to a 3 month wait before you are seen for your initial assessment
If you need urgent help, please contact your GP or the NHS via 111

Note on Consent

Please ensure appropriate consent has been obtained before submitting a referral on behalf of another individual.

If you are self referring please use the self referral form.

Name of Client(Required)

First Last

Date Of Birth(Required)

Gender(Required)

Male

Female

Phone(Required)

Email(Required)

Address(Required)

Our Service currently do not take international clients please only complete the form if you are based in the UK

Street Address Address Line 2 City Postal Code

Preferred method of contact (select as many methods as you prefer) Phone CallTextEmail(Required)

Phone Call

Text

Does the client consent to text messages / voice mail?(Required)

Yes

Languages spoken(Required)

Ethnicity(Required)

Religion(Required)

Preferred method of therapy(Required)

Please specify your preferred days for therapy(Required)

Please specify your preferred time for therapy(Required)

GP name and contact details(Required)

Reason for referral / what problems does he or she have?(Required)

Significant risks(Required)

Referrer's name and contact details(Required)

Same as GP

Other

Referrer's email address(Required)

Self Referral Form(Required)

Price:

Total

Credit Card