Self referral

Self-referral

You’re already halfway there

You’ve made it this far, and you deserve to keep going. Tell us about yourself, or a loved one you want to help. In a few short clicks you’ll be connected with us, and we can arrange a chat. Simple, easy, no confusion.

0800 047 6861

Working in partnership with

Step 1 of 7

Please select which applies to you

I am 16 year or older

Everyone 16 years and older can receive free treatment. No matter your gender, religion or sexual orientation.

I am younger than 16

Everyone under the age of 16 can access therapy through our charity service. This operates on donations, they are optional but gratefully appreciated.

I am a general practitioner

DRCS is able to provide therapy for professionals outside the NHS meaning you will not be on the system. It costs £40 per session.

Step 2 of 7

Tell us a little about yourself

Gender

GenderqueerFemaleMale

Date of birth

Have you ever been in the armed forces?

YesNo

What problems have you been experiencing in the last couple of weeks?

Little interest in doing thingsTrouble falling or staying asleepFeeling tired or having little energyFeeling down or hopelessPoor appetite or overeatingFeeling bad about yourselfTrouble concentratingMoving or speaking slowlyThoughts of hurting yourself in any wayThinking you would be better of dead

How long have your current problems been present and how have they changed over time?

Which of the following effects can you relate to?

Do you hurt yourself on purpose?

yesno

Have you tried to end your life?

yesno

Do you use alcohol or drugs?*

yesno

Have you been physically violent towards others?

yesno

Which of the following best describes your employment status?

How much do your problems impair your abilities in the following activities? (1 Not at all - 5 Severely)

Work

54321

Home management

54321

Social activities

54321

Private activities

54321

Family and relationships

54321

Your medical details

NHS number

GP surgery

GP name

Are there any professionals involved with the problems you're experiencing right now?

yesno

How can we reach you

Your Name

Your Address

Your Postcode

Your Email address

Your Phone number

Can we call you on this number?

yesno

Can we leave a voicemail?

yesno

By submitting this information, I give permission for my information to be shared with Talking Mental Health Derbyshire to access talking therapies.

Tell us a little about yourself

Gender

GenderqueerFemaleMale

Date of birth

What problems have you been experiencing in the last couple of weeks?

How long have your current problems been present and how have they changed over time?

Which of the following effects can you relate to?

Do you hurt yourself on purpose?

yesno

Have you tried to end your life?

yesno

Do you use alcohol or drugs?*

yesno

Have you been physically violent towards others?

yesno

How much do your problems impair your abilities in the following activities? (1 Not at all - 5 Severely)

School work

54321

Social activities

54321

Private activities

54321

Family and relationships

54321

Your medical details

NHS number

GP surgery

GP name

Are there any professionals involved with the problems you're experiencing right now?

yesno

How can we reach you

Your Name

Your Address

Your Postcode

Your Email address

Your Phone number

Can we call you on this number?

yesno

Can we leave a voicemail?

yesno

Tell us a little about yourself

Gender

GenderqueerFemaleMale

Date of birth

Have you ever been in the armed forces?

YesNo

What problems have you been experiencing in the last couple of weeks?

How long have your current problems been present and how have they changed over time?

Which of the following effects can you relate to?

Do you hurt yourself on purpose?

yesno

Have you tried to end your life?

yesno

Do you use alcohol or drugs?*

yesno

Have you been physically violent towards others?

yesno

Which of the following best describes your employment status?

How much do your problems impair your abilities in the following activities? (1 Not at all - 5 Severely)

Work

54321

Home management

54321

Social activities

54321

Private activities

54321

Family and relationships

54321

Your medical details

NHS number

GP surgery

GP name

Are there any professionals involved with the problems you're experiencing right now?

yesno

How can we reach you

Your Name

Your Address

Your Postcode

Your Email address

Your Phone number

Can we call you on this number?

yesno

Can we leave a voicemail?

yesno

Tell us a little about yourself

Gender

GenderqueerFemaleMale

Date of birth

What problems have you been experiencing in the last couple of weeks?

Little interest in doing thingsTrouble falling or staying asleepFeeling tired or having little energyFeeling down or hopelessPoor appetite or overeatingFeeling bad about yourselfTrouble concentratingMoving or speaking slowelyThoughts of hurting yourself in any wayThinking you would be better of dead

How long have your current problems been present and how have they changed over time?

Which of the following effects can you relate to?

Do you hurt yourself on purpose?

yesno

Have you tried to end your life?

yesno

Do you use alcohol or drugs?*

yesno

Have you been physically violent towards others?

yesno

Which of the following best describes your employment status?

How much do your problems impair your abilities in the following activities?

Work

54321

Home management

54321

Social activities

54321

Private activities

54321

Family and relationships

54321

Your medical details

NHS number

GP surgery

GP name

Are there any professionals involved with the problems you're experiencing right now?

yesno

How can we reach you

Can we call you on this number?

yesno

Self-referral

You’re already halfway there

0800 047 6861

Working in partnership with

Step 1 of 7

Please select which applies to you

I am 16 year or older

I am younger than 16

I am a general practitioner

Step 2 of 7

Tell us a little about yourself

Step 3 of 7

What problems have you been experiencing in the last couple of weeks?

Step 4 of 7

How long have your current problems been present and how have they changed over time?

Which of the following effects can you relate to?

Step 5 of 7

Which of the following best describes your employment status?

How much do your problems impair your abilities in the following activities? (1 Not at all - 5 Severely)

Step 6 of 7

Your medical details

Step 7 of 7

How can we reach you

Step 2 of 7

Tell us a little about yourself

Step 3 of 7

What problems have you been experiencing in the last couple of weeks?

Step 4 of 7

How long have your current problems been present and how have they changed over time?

Which of the following effects can you relate to?

Step 5 of 7

How much do your problems impair your abilities in the following activities? (1 Not at all - 5 Severely)

Step 6 of 7

Your medical details

Step 7 of 7

How can we reach you

Step 2 of 7

Tell us a little about yourself

Step 3 of 7

What problems have you been experiencing in the last couple of weeks?

Step 4 of 7

How long have your current problems been present and how have they changed over time?

Which of the following effects can you relate to?

Step 5 of 7

Which of the following best describes your employment status?

How much do your problems impair your abilities in the following activities? (1 Not at all - 5 Severely)

Step 6 of 7

Your medical details

Step 7 of 7

How can we reach you

Step 2 of 7

Tell us a little about yourself

Step 3 of 7

What problems have you been experiencing in the last couple of weeks?

Step 4 of 7

How long have your current problems been present and how have they changed over time?

Which of the following effects can you relate to?

Step 5 of 7

Which of the following best describes your employment status?

How much do your problems impair your abilities in the following activities?

Step 6 of 7

Your medical details

Step 7 of 7

How can we reach you