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

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Step 1 of 7

Please select which applies to you

A

I am 16 year or older

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

b

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.

c

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

Date of birth




Have you ever been in the armed forces?

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Step 3 of 7

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

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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?

Do you hurt yourself on purpose?

Have you tried to end your life?

Do you use alcohol or drugs?*

Have you been physically violent towards others?

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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)

Work

Home management

Social activities

Private activities

Family and relationships

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Step 6 of 7

Your medical details

NHS number

GP surgery

GP name

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

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Step 7 of 7

How can we reach you

Your Name

Your Address

Your Postcode

Your Email address

Your Phone number

Can we call you on this number?

Can we leave a voicemail?

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Step 2 of 7

Tell us a little about yourself

Gender

Date of birth



Previous
Next

Step 3 of 7

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

Previous
Next

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?

Do you hurt yourself on purpose?

Have you tried to end your life?

Do you use alcohol or drugs?*

Have you been physically violent towards others?

Previous
Next

Step 5 of 7

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

School work

Social activities

Private activities

Family and relationships

Previous
Next

Step 6 of 7

Your medical details

NHS number

GP surgery

GP name

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

Previous
Next

Step 7 of 7

How can we reach you

Your Name

Your Address

Your Postcode

Your Email address

Your Phone number

Can we call you on this number?

Can we leave a voicemail?

Previous

Step 2 of 7

Tell us a little about yourself

Gender

Date of birth




Have you ever been in the armed forces?

Previous
Next

Step 3 of 7

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

Previous
Next

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?

Do you hurt yourself on purpose?

Have you tried to end your life?

Do you use alcohol or drugs?*

Have you been physically violent towards others?

Previous
Next

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)

Work

Home management

Social activities

Private activities

Family and relationships

Previous
Next

Step 6 of 7

Your medical details

NHS number

GP surgery

GP name

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

Previous
Next

Step 7 of 7

How can we reach you

Your Name

Your Address

Your Postcode

Your Email address

Your Phone number

Can we call you on this number?

Can we leave a voicemail?

Previous

Step 2 of 7

Tell us a little about yourself

Gender

Date of birth




Previous
Next

Step 3 of 7

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

Previous
Next

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?

Do you hurt yourself on purpose?

Have you tried to end your life?

Do you use alcohol or drugs?*

Have you been physically violent towards others?

Previous
Next

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?

Work

Home management

Social activities

Private activities

Family and relationships

Previous
Next

Step 6 of 7

Your medical details

NHS number

GP surgery

GP name

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

Previous
Next

Step 7 of 7

How can we reach you




Can we call you on this number?

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