1. 1) Self referral form 
  2. Completed

With You Surrey eReferral

Welcome to the Surrey Self Referral Form

Please be aware that We Are With You does not provide a crisis service. If you need urgent help, you can

  • call your GP and ask for an emergency appointment
  • call NHS 111
  • contact your mental health crisis team on 0800 915 4644
  • call Samaritans free on 116 123 or email jo@samaritans.org

Please complete the form below. *Indicates a required field.

Once you press Submit at the end of this form, you will be invited by text message to book an initial assessment appointment via our online booking calendar.

If you are having any difficulties with completing the referral form please email enquiries@wearewithyou.org.uk or call us on 0300 012 0012.

Indicates a required field

Characters remaining :
*
Characters remaining :
*
Characters remaining :
*
*
*
Characters remaining :
Characters remaining :
Characters remaining :
Characters remaining :
*
*
*
*
*
*
*
*
GP Details
Please note your GP will be made aware that you have entered the We are With You service, and that we will share with them information about your clinical presentation and the agreed treatment plan
*
Demographic Information
*
*
*
Other information
*
Information about your referral

We Are With You takes your privacy seriously. We work in partnership with your GP & share information with them about your care. We will use the information from this form to start a record of your care and help us to keep your GP updated.

If you accept and would like submit your referral please click the 'Submit' button, if you have given permission to receive SMS, you will shortly receive a text message inviting you to book your assessment appointment with us.

Contact Telephone: 0300 012 0012