Important Notice

Please be aware that our service is not designed to provide crisis intervention or emergency support. If you are experiencing a mental health crisis or need immediate assistance, we encourage you to contact the appropriate crisis support services.

NHS Mental Health Team: Call 111 option 2
Emergency Services: Dial 999 for immediate help if you or someone else is in danger.
A&E or Your GP: For urgent reviews of care, you can visit your local Accident & Emergency department or contact your General Practitioner.
Samaritans: Call 116 123 (24/7 emotional support)
Saneline: 0300 304 7000 (4.30pm - 10.30pm every day)

For residents of Buckinghamshire, you can also contact the following crisis support numbers:

Buckinghamshire Mental Health Helpline: Adults: 0800 783 0119 Children: 0800 783 012
Bucks Safe Haven: Call 01494 218098 (6pm-midnight)

Your safety and well-being are important to us, and we urge you to seek immediate help from the appropriate resources in a crisis situation.

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Self-Referral Form

We welcome self-referrals from individuals looking for support with their mental health and emotional well-being. Please complete the form below.

All information you share will be treated with the utmost confidentiality. A member of our team will contact you shortly to discuss your needs and arrange an initial appointment.

Full Name:

Preferred Name:

Email:

Phone:

Date of Birth:

Day

Month

Year

Your appointment preferences:

Online

Telephone

In-Person (in High Wycombe)

Other

Please indicate how you will be funding:

Self-Funding

Insurance Policy

Insurance Details:

If using an insurance policy, please indicate the named insurer and provide your policy and claim number. Note: Please ensure you have pre-authorisation in place before attending your initial session

Brief description of what you’d like support with:

Please briefly describe the difficulties you're facing and what you hope to achieve from attending therapy.

Your Availability:

Please let us know the best times to call you for your initial consultation.

How did you hear about us?

Confidentiality Notice:

All information submitted through this form is kept strictly confidential and used solely for the purpose of arranging your therapy support.

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