Self refer

Fill in this referral form and a friendly member of our team will get in touch with you within 2 working days, to take some more details and arrange your first appointment.

We are not a crisis service. If you feel at risk of harming yourself, or can't keep yourself safe, please visit our ‘Get urgent help’ page for emergency contacts.

Step 1

Introduction

Who is making this referral?

I am referring myself

I am a health or social care professional referring someone else

Referrer details

Are you the patient’s GP?

Yes

No

Your name:

Your job title:

Your organisation:

Your contact telephone number:

Your email address:

Continue to the next step

Step 2

Eligibility check

Check if you are eligible

To access our service, you need to be registered with a GP practice that is local to one of our services.

Visit the NHS website to enter your GP practice postcode and check if it is included in our service areas: Check your GP practice.

Surgery/Doctor Name: *

Surgery Postcode: *

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Try again

Confirm eligibility and continue

Step 3

Your details

Referral form

The minimum age for this service is 17yrs 9 months

Your contact details

First name: *

Last name: *

Date of Birth: *

Gender Assigned at Birth: *

Is Gender Identity the same as Gender Assigned at Birth? *

Yes

No

Gender Identity: *

Home street address line 1: *

Home street address line 2:

Home street address town: *

Home postcode: *

We will need to be able to contact you by phone, so please provide us with at least one number. When we call you, it will be from a withheld number within two working days of you submitting the form. If we can’t reach you, we will send you a text or email, or leave you a voicemail to arrange a convenient time. Please ensure you have consented to at least one of these options.

Phone Number One: *

Can we leave a voicemail on this number?

Yes

No

Can we text you on this number?

Yes

No

Contact Number Two:

Can we leave a voicemail on this number?

Yes

No

Email address:

Can we email you at this address?

Yes

No

When we call you, it will be from a withheld number within two working days of you submitting the form. If we can’t reach you, we will send you a text or email, or leave you a voicemail to arrange a convenient time. Please ensure you have consented to at least one of these options.

By submitting this form, you consent to your information being shared with Everyturn. This information will be handled securely, in line with the Data Protection Act 2018. For full details, read our privacy policy.

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Submit referral form

Referral submitted successfully

Thank you for submitting this form.