Self Referral Form

We have both face to face and remote therapy sessions available.

I am happy to hear about all therapist that could help me, whether remote or face to face

I am happy for therapy to be provided remotely

I need therapy to be face to face in Malvern (I understand there may be less therapists to choose from)

Who is the client?

I am the client and I am 18 years or older

I am completing this form on behalf of someone under 18 years old

NHS involvement

I confirm that the client requesting therapy is not presently open to an NHS mental health team i.e. CAMHS, Early Intervention, CMHT, Crisis Service, Perinatal, Older Adult or Eating Disorders. (This does not include being on a waitlist).

If you are completing this form on behalf of someone else, what is your name and relationship to the client?

What is your best email address?

What is your best contact number (please do not put in spaces - mobiles are ideal as we sometimes need to text)

Client Information

Please tell us a little bit about the person who is interested in therapy

What is your first name?

What is your surname?

What is your age?

Which GP practice are you registered with?

Are you limited to particular session times? (please choose one) Are you limited to particular session times? (please choose one)

How are you wanting to pay for sessions?

Funding sessions myself

Using Health Insurance

If you are paying by Health Insurance, which provider is it? (We will need you to complete an Insurance Form with a claim code, before we can book your session)

Previous Support

It helps guide our decisions to know what therapy has helped/ not helped in the past

Have you had therapy in the past? (please choose one)

If you have had therapy before, what type was it and how long did it last?

How Can We Help You?

Please give us as much detail as you feel comfortable with. The more details you provide the more we can choose the most suitable therapist for your need.

Is there a particular type of therapy that you are enquiring about?

If you would like Relationship (Couple) Therapy, please tell us the (1) Full Name and (2) Email of your partner/ family member who will be attending therapy with you

What is the difficulty that you are seeking support for? ....... Or in what area of your life would you like to see positive changes? (please give as much detail as possible so we can match you to the most helpful type of therapy)

Is the difficulty to do with a specific traumatic event/ or events? (please choose one answer)

Sometimes people have nightmares, intrusive thoughts and/ or flashbacks of past events, suggesting underlying trauma. This is useful for us to know as EMDR may be helpful.

Do you have a preferred therapist? (please leave blank if you are open to our guidance)

Sometimes a different therapist to your initial preference, may suit your needs more, or your preferred therapist could be fully booked. When we review your form we may suggest more than one therapist.

Caring For Your Safety

Is alcohol a significant problem? (please choose one)

Are recreational drugs being used? (please choose one)

Are there any thoughts of suicide? (please choose one)

Have there been any suicide attempts? (please choose one)

If you feel unsafe - either from yourself or someone else - please call 111 and let them know, or 999 if you are in crisis. Other helpful contacts are: 116 123 (Samaritans), 0800 58 58 58 (Calm) or Text “SHOUT” to 85258 or the Domestic Violence Helpline 0808 2000 247 .

Respecting your confidentiality and privacy is fundamental to our practice. Your form will be stored securely in our password protected system and governed by strict GDPR rules. If you book in with one of our therapists they will read your referral form before your initial session. We will not share your information with anyone outside our practice, unless we believe you are at imminent risk of harm (or a child or vulnerable adult is at a serious risk). In this instance we are legally bound to share basic information in order to keep you (or a vulnerable other) safe.

Yes I understand

Do you have a question you would like us to answer?

How did you hear about our service?

Next Steps

We will review your form, answer questions and make recommendations based on which therapists may be most suitable. We aim to provide you with support as quickly and as simply as possible.

We will email our recommendations. (Please check your junk email in case it lands there). You will then be invited to book with your chosen therapist using our online diary, or telephone our office to book.

I will keep an eye out for the email.