Self referral form | Walsall Talking Therapies

Walsall Talking Therapies

Welcome to Talking Therapies.

To get started with your journey we would like to take some details that help us make sure we get the right support for you.

After completing your details we will contact you with an appointment that will allow one of our psychological practitioners to complete a 20-30 minute check up with you. We will just ask you a little more about how you feel. There is a range of options we can offer, we want to make sure we offer the ones most likely to help.

You are in the right place if you are:

Experiencing low mood, anxiety, and stress; and would like to see what support can be offered to help you manage it.

You are registered with a Walsall GP

You are 17 years of age and over

I need help immediately:

If you are in crisis and need help with your mental health as a matter of urgency, we recommend speaking to your GP in the first instance so they can choose the most appropriate NHS service to help.

You can also call the following services for support if you feel you need immediate support:

Samaritans 116 123
24/7 Mental Health Helpline 0345 646 0827

* Indicates a required field

Title *

First Name *

Characters remaining :

Last Name *

Characters remaining :

Date of Birth *

Address Line 1 *

Characters remaining :

Address Line 2

Characters remaining :

Address Line 3

Characters remaining :

Town/City *

Characters remaining :

County

Characters remaining :

Post Code *

Accommodation Type *

Mobile Phone Number *

Is it okay to leave a voice message on your mobile telephone number? *

Yes No

Is it okay to send text messages to your mobile phone?

Yes No

Would you like to receive free text appointment reminders? *

Yes No

Is it OK to send letters to your home address? *

Yes No

Email Address. By providing your email address you will be providing consent for us to contact via email.

Characters remaining :

By email *

Yes No

Is an interpreter required?

Yes No

Interpreter Language

Ethnicity *

GP Surgery *

GP Name *

Characters remaining :

Where did you hear about the service? *

Do you have any on-going physical health problems? *

What is your availability on Mondays? *

AM Only PM Only AM or PM Not Mondays

What is your availability on Tuesdays? *

AM Only PM Only AM or PM Not Tuesdays

What is your availability on Wednesdays? *

AM Only PM Only AM or PM Not Wednesdays

What is your availability on Thursdays? *

AM Only PM Only AM or PM Not Thursdays

What is your availability on Fridays? *

AM Only PM Only AM or PM Not Fridays

Other :

Characters remaining :

I accept terms and conditions. *

Incomplete information

Terms and conditions

Please tick the checkbox to accept the terms and conditions.

An unexpected error occurred

An error occurred with data entry

There was a problem sending these details.
Please check for invalid characters such as quotes (’ ‘ ´ `) and long dashes (– —) in any text you may have typed or pasted in, and try again.

If the problem persits, then please contact your service.

Important Service Message

Important Service Message

Please be advised all calls from us will be from an unknown number.

BCHFT is committed to ensuring all your personal information is held in a safe, secure environment. If you would like to know more, then please review the trusts privacy and data protection notices by clicking on the terms and conditions link above

Contact Telephone: 0800 953 0995

Contact Email: talkingtherapies.walsall@nhs.net