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Healthcare Professionals
Work For Us
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Home
About
FAQs
Healthcare Professionals
Work For Us
- Vacancies
- Life as a Therapist

01483 906392

Health Topics
Treatments & Therapies
SELF-REFER
LOCATIONS
NEWS
CONTACT US
- Complaints & Compliments

Health Topics
Treatments & Therapies
SELF-REFER
LOCATIONS
NEWS
CONTACT US
- Complaints & Compliments

01483 906392

Home
About
FAQs
Helathcare Professional
Work For Us
- Vacancies
- Life as a Therapist
A-Z Health Topics
Treatments & Therapies
SELF REFERRAL
LOCATIONS
NEWS
CONTACT US
- Complaints & Compliments

Home
About
FAQs
Helathcare Professional
Work For Us
- Vacancies
- Life as a Therapist
A-Z Health Topics
Treatments & Therapies
SELF REFERRAL
LOCATIONS
NEWS
CONTACT US
- Complaints & Compliments

SELF REFERRAL FORM

At DHC we aim to provide quality healthcare in local setting for the benefit of patients.

Referral Forms

If you know the treatment you require please complete one of the following forms and we will be in touch.

Computer based CBT

Complete treatment form now

Computer based CBT

Web Site

Title *

First Name *

Last Name *

Email Address *

Date of Birth *

(DD/MM/YYYY)

Gender

Female Male

Address line 1 *

Address line 2

Post Code *

Daytime Contact Number *

Mobile / Alternate Contact Number

Can we leave a message on this number? *

Yes No

Can we send you SMS messages? *

Yes No

Is your GP aware of your self-referral? *

Yes No

Your NHS number (if known)

Name and address of your GP *

Do you speak English *

Yes No

Your Ethnicity (e.g. White British, Black Carribean etc.)

What is your sexual orientation?

Are you pregnant or have given birth in the past 12 months? *

Yes No

Do you have regular access to a Computer, Laptop, Smartphone or other mobile device with access to the internet *

Please describe your current difficulties *

Are you currently taking any medication prescribed by a doctor for Anxiety or depression? *

Yes No

Please specify:

Have you been diagnosed with a severe and enduring mental health condition?

Yes No

If yes please provide treatment details below:

Are you currently (or have been in the last 6 months) receiving any form of therapy from a counselor, therapist, nurse, psychiatrist, psychologist or other?

Yes No

If yes please give details below:

Sometimes when people are experiencing emotional distress they can have thoughts that life is not worth living or harming themselves in some way. Do you feel you can keep yourself self until assessment? *

Yes No

Sometimes when people are experiencing emotional distress they can have thoughts that life is not worth living or harming themselves in some way. Do you fell you can keep yourself safe whilst accessing Silver Cloud? *

Yes No

How did you hear of us? *

We would like to get in touch with you in order to assist you. We will not share your personal information with any third parties without your consent. Please select how you prefer to be contacted. *

Telephone SMS Email

Long Term Conditions Treatment

Complete treatment form now

Long Term Conditions Treatment

Phone

Title *

First Name *

Last Name *

Email Address *

Date of Birth *

(DD/MM/YYYY)

Gender

Female Male

Address line 1 *

Address line 2

Post Code *

Daytime Contact Number *

Can we leave a message on this number? *

Yes No

Mobile / Alternate Contact Number

Can we leave a message on this number? *

Yes No

Can we send you SMS messages? *

Yes No

Name and address of your GP *

Is your GP aware of your self-referral? *

Yes No

Your NHS number (if known)

Do you speak English *

Yes No

Your Ethnicity (e.g. White British, Black Carribean etc.)

What is your sexual orientation?

Are you pregnant of have given birth in the past 12 months? *

Yes No

What long term conditions(s) are you seeking help for? *

Would you consider: (tick all that you would consider)

Work Group 1:1 Online Treatment

Have you been diagnosed with a severe and enduring mental health condition?

Yes No

If yes please provide treatment details below:

Please describe what impact your Long Term condition is having on the way you feel (e.g. low mood, worries about the future, frustrated etc.)

Are you currently taking any medication prescribed by a doctor for Anxiety or depression? *

Yes No

Please specify:

Are you currently (or have been in the last 6 months) receiving any form of therapy from a counselor, therapist, nurse, psychiatrist, psychologist or other?

Yes No

It is common for people with a long term condition to feel that life is not worth living or harming themselves in some way. Do you feel you can keep yourself safe until assessment?

Yes No

If yes please give details below:

How did you hear of us? *

We would like to get in touch with you in order to assist you. We will not share your personal information with any third parties without your consent. Please select how you prefer to be contacted. *

Telephone SMS Email

Group & workshop booking form

Complete course booking form

Group & workshop booking form

Phone

Title *

First Name *

Last Name *

Email Address *

Date of Birth *

(DD/MM/YYYY)

Gender

Female Male

Address line 1 *

Address line 2

Post Code *

Daytime Contact Number *

Mobile / Alternate Contact Number

Can we leave a message on this number? *

Yes No

Can we send you SMS messages? *

Yes No

Is your GP aware of your self-referral? *

Yes No

Your NHS number (if known)

Name and address of your GP *

Do you speak English *

Yes No

Your Ethnicity (e.g. White British, Black Carribean etc.)

What is your sexual orientation?

Are you pregnant of have given birth in the past 12 months? *

Yes No

Which group/workshop would you like to take part in?

What would you hope to gain from the group?

Are you currently taking any medication prescribed by a doctor for Anxiety or depression? *

Yes No

Have you been diagnosed with a severe and enduring mental health condition?

Yes No

If yes please provide treatment details below:

Are you currently (or have been in the last 6 months) receiving any form of therapy from a counselor, therapist, nurse, psychiatrist, psychologist or other?

Yes No

If yes please give details below:

Sometimes when people are experiencing emotional distress they can have thoughts that life is not worth living or harming themselves in some way. Do you feel you can keep yourself safe whilst accessing Silver Cloud?

Yes No

How did you hear of us? *

We would like to get in touch with you in order to assist you. We will not share your personal information with any third parties without your consent. Please select how you prefer to be contacted. *

Telephone SMS Email

Talking Therapies Treatment

Complete treatment form now

Talking Therapies Treatment self referral

Order Number

Title *

First Name *

Last Name *

Email Address *

Date of Birth *

(DD/MM/YYYY)

Gender

Female Male

Address line 1 *

Address line 2

Post Code *

Daytime Contact Number *

Mobile / Alternate Contact Number

Can we leave a message on this number? *

Yes No

Can we send you SMS messages? *

Yes No

Name and address of your GP *

Is your GP aware of your self-referral? *

Yes No

Your NHS number (if known)

Do you speak English *

Yes No

Your Ethnicity (e.g. White British, Black Carribean etc.)

What is your sexual orientation?

Do you suffer from any of the following long term conditions?

Asthma

Cancer

Cardiovascular conditions

Carpal tunnerl syndrome, other repetitive strain conditions

Chronic fatigue/ME

COPD

Crohns/Diverticultis/other inflammatory bowel conditions

Dementia

Diabetes

Epilepsy

Gynaecological problem (e.g. endometriosis, polycystic ovaries)

Heart Failure

HIV

Hypertension (high blood pressure)

Irritable bowel syndrome (IBS)

Liver / Kidney disease

Neurological condition (e.g. MS, stroke, Parkinson's)

Sickle cell

Systemic lupus erythmematosus

Thyroid conditions

Other

Are you pregnant of have given birth in the past 12 months? *

Yes No

Are you currently taking any medication as prescribed by a doctor *

Yes No

Have you been diagnosed with a severe and enduring mental health condition? *

Yes No for example, Bi-polar, Schizophrenia or a personality disorder

Are you currently (or have been in the last 6 months) receiving any form of therapy from a counsellor, therapist, nurse, psychiatrist, psychologist or other? *

Yes No

Please briefly describe your current difficulties that you would like to address *

Sometimes when people are experiencing emotional distress they can have thoughts that life is not worth living or harming themselves in some way.

Do you feel you can keep yourself safe until assessment? *

Yes No

How did you hear of us? *

We would like to get in touch with you in order to assist you. We will not share your personal information with any third parties without your consent. Please select how you prefer to be contacted. *

Telephone SMS Email

If you are unsure of the treatment you require please complete the Talking Therapies form and we will be in touch

Follow Us

Get in touch

01483 906392

Self refer online

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© Dorking Healthcare Ltd
Registered no. 06927650 | DHC are registered with the Care Quality Commission
Registered office: The Surgery, Tanners Meadow, Brockham, Surrey RH3 7NJ