Need Urgent Help

Back to top

Professional Healthcare Referral

Please complete all the details in the form below.

You should make sure that:

  • You double check all telephone numbers so we
are able to contact the patient.
  • Referral must include PHQ9 and GAD7 scores to
help our screeners and therapists.
  • All fields must be completed otherwise you will not be
able to submit the form.
older man on the phone

"*" indicates required fields

1General Information
2Current Patient Condition

General Information

Has the patient consented to this referral?*
Name*
DD slash MM slash YYYY
If the patient has a preferred name they would like us to use in conversations and correspondence with them, please let us know here. (Their legal name will still have to be used for their NHS medical records)
Can we leave messages? (Main)
Can we leave messages? (Other)
Can we send text messages?
Postcode*
Does the patient speak English* If not, preferred language

Possible Risk?*
Any Mental Health Diagnosis?*
Has the patient got a history of substance use?*