Refer yourself

Name*
Phone number (preferably mobile)*
Email address (if applicable)
Postal Address*
Postcode*
Name, address and postcode of your doctor’s (GP) surgery.*
Please note that we will contact you initially, to arrange an appointment, via a text message, if you have provided us with a mobile phone number. If it is not possible for you to pick up or reply to text messages, please indicate below how you would like us to make initial contact with you.
Best hopes: please use the space below, if you wish to, to tell us what you would like to get out of talking to us. For example, some people tell us things like “I would like to feel better about myself” or “I want to move on from my past difficulties”. It is up to you how much you tell us here, but anything you do say will be held securely and in confidence along with the personal contact information you have provided.
Age*
I confirm that I am aged 18 or over*
Consent*
I agree to be contacted using the personal data that I have provided*

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