PH initial contact form


NHS Practitioner Health is a primary care mental health and addiction service for health and care staff. We exist to help those members of the workforce who, due to confidentiality reasons, cannot access care or treatment locally.

We understand the special needs of healthcare professionals with mental illness or addiction, how their role might impact on their ability to receive confidential care; and how their condition might impact on their work and potentially their own patients. We work in the unique interface between health and care practitioners as regulated professionals and as patients with a mental illness, and as such we may also be able to offer some additional expertise where staff are undergoing an investigation or complaint and mental illness may have played a part in this.

The service will assess all referrals and registrations to consider if we are able to offer a route to treatment, or if signposting to an alternate confidential support offer would be beneficial. Please be aware that our clinicians and therapists are unable to consult with patients who are abroad.

You are being asked to complete the form below to enable us to assess your suitability for the service and direct you to the most appropriate help for your situation. Please provide as much detail as possible so that we are able to fully understand your circumstances. All information you provide will be treated in strictest confidence and will not be shared outside of the service without your knowledge and consent.

What happens next?
Upon completion of this form we will review the information you have provided and will aim to contact you either by email or phone within the next 5 working days. If you are assessed as suitable for the service we will send you details on how to book your initial appointment with a clinician or therapist.
If we feel your needs would be better met elsewhere we will provide you with the details of how to access this help.

If you have any problems completing this form please email or call 0300 0303 300 during office hours (8am - 8pm Monday to Friday, 8am - 2pm Saturday). Please note we are not open on bank holidays. 

Please note that NHS PH is not a crisis service. If you are in crisis or feel unsafe or at risk to yourself or others, then you should contact 111/999, your own GP or attend your nearest Emergency Department/A&E as soon as possible. NHSPH does provide a crisis text service and you can access this by texting "NHSPH" to 85258. 

The Samaritans: 0161 236 8000 (local call charges apply) or 116 123 (free to call) can also be provide confidential support and are open 24 hours a day.

We ask you to complete health screening questionnaires at the end of the form.  They are really important in enabling us to help you quickly.  They take a bit of time but please do complete them.  
Please note the following information: This online form was created by NHS Practitioner Health (NHSPH) using SmartSurvey. Your answers will only be seen by NHSPH. The following information is NOT recorded or tracked when you complete this form: your IP address, your location, your browser or operating system. SSL (Secure Socket Layer) Connections are enabled. This survey is not indexed by search engines. SmartSurvey use a secure UK-based server.

This form is secured through SSL encryption and your data is password secured at NHSPH, it is only accessible by staff with two factor authentication (only accessible by having a password and a second device with a code). All data is stored on UK/EU-based servers (for further information can be found at In addition to these measures once a referral is received all data is removed from the server within two weeks.

This form has the following sections and will take approximately 30-45 minutes to complete.
2. About you
3. Your health
4. Consent
5. Your role
6. Demographics
7. Future contact
8-12. Health Screening Questionnaires