• Your service

  • Your details

  • We really need this, if possible. You can find your NHS number on:
    • A medical card
    • A letter from your GP or a hospital
    • A printed prescription
  • How we contact you

  • We will try to contact you by telephone unless otherwise advised. If possible, please provide a mobile number in addition to a landline.
  • Please tick A, B or C if you give permission for us to:
  • Your GP's details

  • For example: Dr Smith
  • You can find your GP's address by visiting the NHS Service Search
  • We are required to notify your GP that you are accessing our service. Please provide permission for us to write to your GP with this information. Please note that if you do not give permission we are unable to offer you this service.
  • Presenting Problem

  • About you

  • This field is for validation purposes and should be left unchanged.

Struggling to cope?

Don’t struggle alone overnight. If you’re experiencing anxiety, panic attacks, depression, suicidal thoughts or are in crisis, call us from 6pm - 1am.

If you are in crisis overnight from 6pm - 1am, call us on: 0300 003 7029