Referral Form

If you are 17+ and registered with a Surrey GP, complete our self-referral form below to access online CBT via SilverCloud.

If you have already completed a referral form for 1-2-1 support with DHC Talking Therapies, then please do not complete another form. Contact us directly on 01483 906392 or iapt.dhc@nhs.net if you have any questions about your referral.

Title:*

First Full Name:*

Last Name:*

Preferred Name:

Date of Birth:*

Gender:*

Address Line 1:*

Postcode:*

Are you happy for us to send letters to your home address?:*

Yes

No

Email Address:*

Mobile Number:

May we leave a message on this number?:

Yes

No

Would you like text reminders of appointments?:

Yes

No

Home Number:

Please select how you prefer to be contacted.*

Telephone

SMS

Email

GP Practice:*

Are you happy for us to send updates to your GP regarding your treatment and care?:*

Yes

No

(Please note: If you select No, but in the future we are concerned about your safety, someone else’s safety or if you were involved in a serious crime, we would be required to update your GP and the relevant services)

Your NHS number (if known):

Ethnicity:

Sexual orientation:

Religion:

Ex-British Armed Forces:

Do you have any Long Term Conditions? If yes, please provide details:

Disability:

Are you current pregnant or have a child under the age of 1 year?:

Yes

No

Emergency Contact and Phone Number:*

In 1-2 sentences, please tell us your reason for referring to SilverCloud:*

Please complete the captcha

Self Referral Form