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Fields marked (*) are required
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?
Do you know where we are?
Do you need directions?
Would a text reminder of appointment be helpful?
Would providing local transport information be helpful?
We will need to contact your doctor to tell him/her that you are accessing CBT.
Doctor's Telephone Number
If a service is helping you to complete this referral
This information is collected for statistical reasons and no contact will be made with the service without your permission