NHS General Practitioner Health Service Self-Referral Form

1. Self-Referral Information

Please give us as much information as possible so that we can provide you with the most appropriate care. Please be assured that any information you provide will be kept in the strictest confidence.
 

1. Please provide your name, email address and a daytime telephone number that the NHS General Practitioner Health Service (NHS GPH) can call you on to discuss your self-referral. *

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2. To let us know how we can best help you, please tick any of the following statements that apply. All information you provide will remain strictly confidential and will not be shared. *

 

3. To help us understand how we can help you, please can you briefly describe your current circumstances and how you would like us to help.

 
If you are unsure about completing this form please email us on gp.health@nhs.net and a member of the NHS GPH will contact you by phone during office hours to advise you.

Alternatively you can speak to us directly on 0300 030 33 00 or visit our website for further information on NHS GPH or the services we provide. (www.gphealth.nhs.uk)

Our administrative office is open from 8am to 8pm Mondays to Fridays and 8am until 2pm on Saturdays.