Self 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:*
Please Select A Value...
Mr
Mrs
Miss
Ms
Mx
Dr
Rev
Prof
First Full Name:*
Last Name:*
Preferred Name:
Date of Birth:*
Gender:*
Male
Female
Non binary
Not known
Not specified
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:
Please Select A Value...
White - British
White - Irish
White - Any other White background
Mixed - White and Black Caribbean
Mixed - White and Black African
Mixed - White and Asian
Mixed - Any other mixed background
Asian or Asian British - Indian
Asian or Asian British - Pakistani
Asian or Asian British - Bangladeshi
Asian or Asian British - Any other Asian background
Black or Black British - Caribbean
Black or Black British - African
Black or Black British - Any other Black background
Other Ethnic Groups - Chinese
Other Ethnic Groups - Any other ethnic group
Not Stated - Not Stated
Not known - Not known
Sexual orientation:
Please Select A Value...
Heterosexual
Lesbian or gay
Bisexual
Other
Not known
Not stated
Religion:
Please Select A Value...
No religious group or secular
Atheist / Agnostic
Buddhist
Church of England
Hindu
Jain
Jewish
Muslim
Orthodox Christian
Orthodox Jewish
Other Christian
Other protestant
Parsi / Zoroastrian
Rastafarian
Roman Catholic
Shi'ite Muslim
Sikh
Sunni Muslim
Any other religion
Not stated
Ex-British Armed Forces:
Please Select A Value...
Yes - ex services
No
Dependant of a ex-serving member
Not stated (Person asked but declined to provide a response)
Unknown (Person asked and does not know or isn't sure)
Do you have any Long Term Conditions? If yes, please provide details:
Disability:
Please Select A Value...
No Disability
Behaviour and Emotional
Hearing
Manual Dexterity
Memory or ability to concentrate, learn or understand (Learning Disability)
Mobility and Gross Motor
Perception of Physical Danger
Personal, Self Care and Continence
Progressive Conditions and Physical Health (such as HIV, cancer, multiple sclerosis, fits, etc)
Sight
Speech
Other
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
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