NHS Practitioner Health Self Referral

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.  Please note that we are not a crisis service and if you are feeling suicidal or unsafe, you should contact your GP, dial 111, attend A&E, call the Samaritans and/or use the Crisis Text service on our website (www.practitionerhealth.com).

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


2. To let us know how we can best help you, please answer yes or no to all the following questions. All information you provide will remain strictly confidential and will not be shared. *

I am currently registered with the General Medical Council (GMC)
I was registered with the GMC within the last 12 months
I am a doctor working in England
I am a dentist working in England
I am a doctor or dentist training under a London deanery
I am a doctor or dentist training under KSS
I am a GP or GP trainee on the performer's list in England
I am resident in London

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 prac.health@nhs.net and a member of the NHS PH operations team 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 PH or the services we provide. (www.practitionerhealth.nhs.uk)

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