Self referral - DHC Talking Therapies

Title

First Name

Last Name

Email Address

Date of Birth

(DD/MM/YYYY)

Please note: Clients must be 18 or over to use this service. If you are under 18, please see your GP or call us on 01483 906392 for advice.

Gender

Female Male Non-binary

Are you pregnant / 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?

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

On submitting your form, you will receive a confirmation email explaining what will happen next.

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.

Talk to us, self-referral

Talk to us, self-referral

On submitting your form, you will receive a confirmation email explaining what will happen next.

Can you keep yourself safe?