1. 1) Self referral form 
  2. 2) PHQ9 
  3. 3) GAD7 
  4. 4) Phobia 
  5. 5) WSAS 
  6. 6) IAPTEmployment 
  7. Completed

NHS Cambridgeshire & Peterborough Talking Therapies

Welcome to the Talking Therapies Self Referral Form.

If you are in a mental health crisis and need urgent support, please contact our First Response Service on 111, then press the mental health option. Other helpful numbers include:

  • Your GP, Urgent Care (out of hours GP call 111) or A&E

  • The Samaritans tel: 116 123 email jo@samaritans.org

  • SANEline 0300 304 7000 (Open 4.30pm - 10.30pm daily)

    • Before completing the self-referral form, we recommend that patients with more severe psychological problems see their GP, who will be able to direct to appropriate services as certain groups fall outside the remit of the service, e.g.

  • Mental illness (e.g. Psychosis or Bipolar illness)

  • Personality disorder

  • Patients with a risk of harm to themselves or others

  • Drug or alcohol dependence

    • The form normally takes between 10-20 minutes to complete. Due to security measures the form will remain open for 40 minutes and will automatically close if it is not completed in this time.

    When completing this referral form you cannot navigate back to review/ amend previous pages. Please do not click the back button on your browser.

    If you have any questions please telephone 0300 300 0055 for help

    If you experience any technical problems filling in the form online, then please contact the Single Point of Access on 0300 300 0055. Please check your spam email folders for email receipt of your self-referral if you have requested this.

    In order for us to be able to treat and support you, we will need to contact your GP for further information. By completing this self-referral form, you are giving us your consent for us to do so.

    Indicates a required field

    *
    *
    Characters remaining :
    Characters remaining :
    *
    Characters remaining :
    *
    *
    *
    *
    *
    *
    *
    *
    *
    Characters remaining :
    Characters remaining :
    Characters remaining :
    *
    Characters remaining :
    *
    *
    *
    *
    *
    Would it be okay for us to contact you via SMS (Text message) about your appointments.
    *
    *
    In order for us to be able to treat and support you, we will need to contact your GP for further information. By completing this self-referral form, you are giving us your consent for us to do so.
    *
    *
    *
    *
    *
    *
    *
    *
    Characters remaining :
    *
    Characters remaining :
    *
    Characters remaining :
    *
    Characters remaining :
    *
    Characters remaining :
    *
    Characters remaining :
    *
    Characters remaining :
    *
    Characters remaining :
    Characters remaining :
    Characters remaining :
    *
    Characters remaining :
    *
    Characters remaining :
    *
    Please note this is a self-referral and should be completed by the participate needing this service / Alternately a professional referral can be completed
    Characters remaining :

    I understand that it will be necessary to access medical notes and share information, where relevant, with my General Practitioner. If there are any issues with this, please let us know at your assessment as we may be unable to offer treatment without access to relevant information. Please note this is routine practice to ensure safe delivery of psychological treatments.


    Before self-referring we recommend that patients with more severe psychological problems see their GP, who will be able to direct to appropriate services as certain groups fall outside the remit of the service, e.g.

    • Mental illness (e.g., Psychosis or Bipolar illness)
    • Personality disorder
    • Patients with a risk of harm to themselves or others
    • Drug or alcohol dependence

    If you are in a mental health crisis and need urgent support, please contact our First Response Service on 111, then press the mental health option. Other helpful numbers include:

    • Your GP, Urgent Care (out of hours GP call 111) or A&E
    • The Samaritans tel: 116 123 email: jo@samaritans.org
    • SANEline 0300 304 7000 (Open 4.30pm - 10.30pm daily)

    Contact Telephone: 0300 300 0055

    Contact Email: selfreferIAPT@cpft.nhs.uk