This form has been designed to ensure we can give you the most appropriate support.
Please complete all the questions fully as the more information we have about your symptoms the better we are able to support you. Please note that all sections marked with (*) must be completed.
It takes approximately 15 minutes on average to complete this form.
Your NHS Number
Before you start, please ensure that you have your NHS Number at hand. Please note that we will not be able to process your referral without it.
You should be able to find your NHS Number on any letter or document you have received from the NHS, including prescriptions, test results, and hospital referral or appointment letters. Each NHS Number is made up of 10 digits shown in a 3-3-4 format (e.g. 000-000-0000). If you cannot find your NHS Number at home, you can ask your GP practice to help you. They should be able to provide the number for you as long as you are registered with them. For more information on how to find your NHS Number please click here
Once you have submitted your self-referral, a confirmation email will be sent to the email address you have provided. If you have not received a confirmation email, please check your Junk E-Mail folder.