Online Referral

Please Confirm the Following:

  • You are NOT in crisis or requiring urgent help today (if you are, please visit our Urgent Help page).
  • You ARE aged 16 or over and ARE registered with a local GP in Teesside (if you are not, please contact your GP to arrange a consultation).

Online Referral Form

Please note: What you share with us remains confidential within the service. The exceptions to this include if you mention any serious risk of harm towards yourself, towards others e.g. child protection or any serious criminal acts e.g. crimes police aren't aware of, including terrorism. As we are an NHS service, we keep details about you as your GP surgery does. These are stored on a secure patient record system.

Your Details

Contact Details

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More About You

GP Details

Current Prescribed Medication

Previous or Current Service Involvement

Reasons for Referral

Next of Kin