Pre-update Self-Referral/Optin replaced Dec 19


You may use our web site freely but you can only self-refer if your GP is in Yateley, Fleet, Farnborough, Blackwater, Aldershot or Farnham

Please complete all the details in the form below and then click the 'Send to TalkPlus' button

You should make sure that:

- you double check any telephone numbers you give us as we will use them to contact you;

- all fields must be completed otherwise you will not be able to click the 'Submit to TalkPlus' button

- look out for a call from our main number which is 01252 533355, we don't withhold our number.


Title (required)

Forename (required)

Surname (required)

Date of Birth (required)

Address (required)

Postcode (required)

Main Contact Number (required)

Can we leave messages? YesNo

Secondary Contact Number

Can we leave messages? YesNo

Can we text message you (for appointments etc.) YesNo

Your Email (required)

Can we email treatment forms? YesNo

Gender (required)

Ethnicity (required)

Religion (if none, enter 'none')

Relationship Status (required)

Sexual Orientation (required)

Please say where you heard about our service

ex-Armed Forces (required)

If ex-Armed Forces is your problem related to your service

Are you, or your partner, pregnant or do you have a baby under 12 months old? (required)

Do you have a disability we should take into account when allocating appointment premises? (required)

Do you have a long-term physical health condition? (required) If 'Yes' please describe

Does your doctor know you are contacting us? (required)

Registered GP Surgery? (required)
Remember, to self-refer your GP must be in Yateley, Fleet, Farnborough, Blackwater, Aldershot or Farnham

Registered GP name? (required)



Please select your main problem (required)

Please give any further details that you feel would help us understand your current problem?


(e.g. CMHRS, Psychiatrist or other Therapist)

Name of Previous Therapist?

Type of Therapist? (e.g. Counsellor, Psychiatrist)

Name of Service?

When did you access this service?

Are you taking any medication for depression or anxiety? Please give details (required)

If so, are you taking it regularly?

Preferred day for us to call you (required)

Preferred time slot for us to call you (required)


Your answers to the following questions will help us assess your current condition. Your referral cannot be submitted until this section is fully completed.

Please indicate how often you have been bothered by the following problems over the last two weeks:


Little interest or pleasure in doing things

Feeling down, depressed or hopeless

Trouble falling or staying asleep, or sleeping too much

Feeling tired or having little energy

Poor appetite or overeating

Feeling bad about yourself, or that you are a failure, or have let yourself or your family down

Trouble concentrating on things such as reading a newspaper or watching television

Moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety or restless that you have been moving around a lot more than usual

Thoughts that you would be better off dead or of hurting yourself in some way

If you have chosen 1,2 or 3 on the last question, please answer the following question:
Do you have any active plans about harming yourself?



Feeling nervous, anxious or on edge

Not being able to stop or control worrying

Worrying too much about different things

Trouble relaxing

Being so restless that it is hard to sit still

Becoming easily annoyed or irritable

Feeling afraid as if something awful might happen



On a scale of 0-8, please select a number to indicate how much you would avoid the following:

Social situations, due to a fear of being embarrassed

Avoid situations for fear of a panic attack/distressing symptoms (vomiting/dizziness)

Avoid objects/activities (animals/heights/seeing blood/driving)



On a scale of 0-8, please select a number to indicate how much your problems impact on the following areas of your life:

Work (If you are retired or choose not to work, please enter 0)

Home Management

Social leisure activities

Private leisure activities/Hobbies

Family and relationships



Please select the option that best describes your current employment status

Are you currently receiving any of the following:

We may use and share your NHS Number and non-identifiable data about your treatment to provide statistics on the performance and effectiveness of our service with NHS England, NHS Digital and the local NHS Clinical Commissioning Group relevant to your area.
Please check here to acknowledge your consent Yes