Quick Exit

GP Referral Form

This form is for NHS General Practitioners to refer patients aged 11-25 to our counselling services. All referrals are reviewed by our clinical team. Please ensure you have the patient's consent before submitting.

Not a GP or healthcare professional?

If you're a young person or parent/guardian, please use our Self Referral Form instead.

For general enquiries, use our Contact Form.

Section A: GP Verification

Your identity will be verified via GMC register and NHS email. GP details are not stored in our database.

As registered with the GMC
7-digit GMC registration number
Must be @nhs.net or @nhs.uk
Full practice name
5-6 character code (e.g., A12345)
For safeguarding escalations

Section B: Patient Information

10-digit NHS number
For appointment confirmations

Parent/Guardian Details (if patient is under 18)

Required if patient is under 18
e.g., Mother, Father, Legal Guardian

Section C: Presenting Issue / Clinical Information

Clinical justification for referral
Any relevant medical, social, or family history
Include dosage if relevant
Optional - if formally diagnosed

Section D: Risk Assessment & Safeguarding

Important: Referrals with moderate or high self-harm risk will be automatically rejected. Please refer these cases to NHS crisis services or CMHT.

AUTO-REJECT if Moderate or High

Section E: Suitability Screening

Submission will be blocked if 'No'

Section F: Consent & Information Sharing

All consent checkboxes must be confirmed before submission.

Mandatory
Mandatory
Mandatory