Self Referral Form:

You can self-refer over the phone by calling 01642 573924 or by completing our online self-referral form. We also accept referrals made to the service from GP's and other professionals via the Professional Referral Form. We cannot accept referrals made by partners, family members or friends.

Are you in crisis now?


Your response to this question has indicated that Impact on Teesside is not the most appropriate service for you. If you are having thoughts about harming yourself, you are in crisis and need urgent help today, you can access immediate support from the following:

Teesside Crisis Team
Telephone: 0800 0516 171 (24 hours per day)
The Crisis Team operates 24 hours a day, 7 days a week. However, they do not provide an 'emergency' service such as a 999 response.

Telephone: 116 123 (24 hours per day)
E mail:

NHS Direct
Telephone: 111 (24 hours per day)
Text phone: 18001 111

Are you completing this form for yourself? (i.e. not on behalf of someone else)


You cannot fill in this form on behalf of someone else. If you are a professional wishing to refer a patient please visit our professionals page.

Are you aged 16 or over?


We are not able to treat people aged under 16. If you are aged 15 or under and wish to access talking therapy please make an appointment with your GP to discuss the available options.

Are you registered with a GP practice in the Teesside area (Hartlepool, Middlesbrough, Redcar & Cleveland and Stockton-on-Tees)?


If this is not the case you can find your local talking therapy service by visiting the NHS Choices website at

Will you be available for a 30-45 minute telephone triage in the next two weeks?


If this is not the case please make contact again when you do have availability in the next fortnight.

Online Self Referral Form

By completing and submitting this form you are agreeing for your information to be stored on our confidential service database. This information is held securely and is not viewed by anyone outside of Impact on Teesside.

* = Mandatory Fields

Personal Details

You can find your NHS number here:

Additional Information

If yes, please select the most appropriate from the list:

If yes, please select the most appropriate from the list:

Reason for Referral

Please tell us why you have contacted us for support: *

Consent to process referral

To process your referral we do need to ensure that you are aware of how we look after your records, the main points are:

  • We share information about your care with your GP
  • We share information with the Department of Health and other healthcare providers such as your GP about the contact you have or have had with them or us; this is for statistical purposes only
  • If you have questions about how we manage your information, you are welcome to discuss these with any staff member involved in your care.
  • Further Information can be found in the link to 'I accept terms and conditions'

What Happens Next

After you submit this form our admin team will contact you by telephone within five working days to arrange a telephone triage with a practitioner. This telephone triage will take approximately 30-45 minutes and will help us clarify your needs and determine whether this is the best service for you. Please be aware that if we cannot make contact with you to progress your referral, you will be discharged from the service and will need to contact us to make a new referral.

Please be aware that when we call you our telephone number may display as no caller ID on your phone. We are a paperless service and correspond by telephone, text and email where possible.