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Working in partnership with the

There’s no need for anyone to
deal with problems alone

  • Self-referral

  • There is no need for anyone to deal with mental health problems alone. Complete our self-referral form below to access our service. Our service is funded by the NHS, so there is no cost to you. You must, however, be registered with your local GP to access the service. And aged over 18 years old if live in Nottinghamshire and over 16 years old in Derbyshire.

    If you can’t locate your GP surgery in the list provided, or need help completing the form please call us for assistance on:

    – 01332 265 659 for Derbyshire
    – 0115 896 3160 for Nottinghamshire 

    Once you have completed the form and pressed submit you will receive an automated email. By submitting your referral you consent for us to share your information on our systems and to contact you regarding the information you have provided. For further information, please refer to our Privacy Statement.

    Please note if you are referring for couples therapy, you and your partner will need to complete a referral form.

  • Over the last 2 weeks, how often have you been bothered by any of the following problems?
  • Not at all Several days More than half the days Nearly every day
  • Over the last 2 weeks, how often have you been bothered by any of the following problems?
  • Not at all Several days More than half the days Nearly every day
  • How much would you avoid each of the following situations?
  • Would not avoid Slightly avoid Definitely avoid Markedly avoid Always avoid
  • People's problems sometimes affect their ability to do certain day-to-day tasks in their lives. How much do your problems impair your ability to carry out the following activities?
  • Not at all Slightly Definitely Markedly Severely

    • Contact us for more information at: Derbyshire 01332 265659 Nottinghamshire 0115 896 3160 Wirral 0151 909 3787

    Working in partnership with the