Fields marked (*) are required

Your Email*

Name

Address

Current Contact Number

Date of Birth

In your own words, tell us what is worrying you?

Are you seeing your doctor or anyone else?

Would you like to try cognitive behaviour therapy to see if this could help you?

Can you tell us if you are on any tablets or medicines for anything?

Is there anything else you would like to tell us that you think is important?

If an appointment is made

Is there any reason you might not be able to make it?
Yes No

Do you know where we are?
Yes No

Do you need directions?
Yes No

Would a text reminder of appointment be helpful?
Yes No

Would providing local transport information be helpful?
Yes No

We will need to contact your doctor to tell him/her that you are accessing CBT.

Doctor's Name

Doctor's Address

Doctor's Telephone Number

If a service is helping you to complete this referral

Service name

This information is collected for statistical reasons and no contact will be made with the service without your permission