If you would like to self-refer to either our NHS or Private therapies, please complete the form below.

Disclaimer:

Please note that due to the high demand for our service in the Swale (Sittingbourne, Isle of Sheppey, etc.) area, there is a 30 day waiting period for any self re-referrals to our service from the discharge date of your last treatment episode.  This means that when you complete any current treatment with our service you will have to wait 30 days before re-referring to our service. However, if you feel you cannot wait that long, we will accept a referral from your GP within this time.

Clinical Commissioning Group imposed waiting period:  If your GP is registered in the Canterbury and Coastal areas, once you have been discharged from our service, there is a waiting period of 12 weeks before you are able to self-refer back to our service.  However, if you feel you cannot wait that long, we do accept referrals from your GP within this time.

Please note all fields are required to complete your registration.

Referral form

What type of referral are you making? *
Please choose one of the following options. If you choose Couples Counselling, please fill in your partner's details in the notes section below.
If you have chosen Couples Counselling, please fill in your partner's full name and contact information here. Please note we cannot process your registration without your partner's contact information and agreement to treatment.
Name *
Name
Your Address *
Your Address
Please make sure the address and postcode given is the address registered with your GP surgery
Please let us know the best number we can contact you on. Please bear in mind we are only able to contact you for completion of registration between 9:30am and 4:30pm Monday to Wednesday and 9:30am to 1:30pm Thursday and Friday.
Can telephone messages be left? *
Please enter the name of the surgery and not your GP.
How would you describe your nationality? *
How would you describe your ethnicity?
Do you have a disability? *
If you do not have a disability please insert "N/A" in the box below.
Long Term Conditions *
Do you have any of the following Long Term Conditions?
If you ticked "Other Medical Condition", please specify below.
Employment status *
Do you have any military experience? *
If you tick "Yes", further information will be required.
Have you had any thoughts of suicide or self harm within the past two weeks? *
Please select which treatment location you would prefer to attend. *
Please tick all that apply. Please note: choosing more than one location helps us in allocating you to a therapist within a quicker time frame.
What time of day would be best for your appointment? *
Tick all that apply
What day of the week would be best for your appointment? *