SELF REFERRAL FORM At DHC we aim to provide quality healthcare in local setting for the benefit of patients. Order Number Title * Mr Mrs Miss Ms First Name * Last Name * Email Address * Date of Birth * (DD/MM/YYYY) Gender * Female Male Are you pregnant or have given birth in the past year? * Yes No 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 Name and address of your GP * Your NHS number (if known) Are you registered with a GP in Surrey? * Yes No If you are interested in either of these particular treatments please tick: Online Treatment? Workshops and Courses? How did you hear of us? * GP Event Social Media Website Publication 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 Can you keep yourself safe? We are not a crisis service and our service only operates Monday to Friday. For crisis support, please contact the Mental Health Crisis Line on 0300 456 8342, the Samaritans on 116 123 or your GP. You could also visit a local 'safe haven' for support (Find your local safe haven: https://www.sabp.nhs.uk/our-services/mental-health/safe-havens). For immediate support if you cannot keep yourself safe call 999 or go to A&E.