• Your service

  • Referrers’ details

  • Details of the person you are referring

  • We really need this, if possible. NHS numbers can be found on:
    • A medical card
    • A letter from a GP or a hospital
  • Getting in touch with the person

  • Please tick A, B or C if you give permission for us to:
  • GP's details for the person being referred

  • 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. Unfortunately if your GP is not listed in the drop down we are unable to offer you support via our service. Please search NHS choices for your local IAPT provider.
  • 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

  • Additional information

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