Adult Self-Referral Form for General Therapies Services

Adult Self-Referral Form for General Therapies Services

If you would prefer this form in another language or in large print, or you would like to make your referral over the phone, please speak with one of our specialist administrators on either of these numbers:
York: 01904 412551
Manchester: 0161 445 2099

Do you have a preference of how you attend your appointments?*
*If you have online sessions your therapist may be based in another town so it may not be possible to see the same therapist if you decide to change from online to face to face appointments.
Which location would you prefer to attend for face to face therapy?*
Your Details
Preferred Method of Contact*
What ethnicity best describes you?*
Equality Diversity and Inclusion Information
Your GP's Details
About Your Referral
What type of support are you looking for?
Are you involved with any mental health services at present?*
Have you had any therapy before?*
Are there any current concerns or risks relating to your physical health? For example, any disabilities, weight, diet, use of drugs/alcohol or sleep.*
We are asking the following two questions to make sure that we can care for you safely. If we are concerned that you or somebody else is at risk of harm and our therapy services are not best placed to support you we may need to suggest alternative support to you and we may need to share information with other healthcare professionals in an attempt to keep you or somebody else safe.
Within the past few weeks, have you experienced any suicidal thoughts and / or thoughts of harming yourself in any way?*
Have you ever caused harm to any other person and/or having thoughts to do so?*
How are you funding your therapy?*
To help us understand how you chose our service, could you please indicate how you heard about The Retreat Clinics by selecting one of the below:
Would you like to receive information about The Retreat's other services? You can opt out at any time.
Data Protection

For the purposes of the General Data Protection Regulations 2016 (GDPR) / Data Protection, The Retreat Clinics is the data controller for the collection, processing, sharing and storage of this data. All information collected in this form will be for the sole purpose of providing a clinical service to you and will only be passed to third parties who support us in the administration of this service or where we have your consent to do this.

However, we may have to break this confidentiality where we have a legal obligation to comply with the law, for example if the information is required to detect a crime or apprehend an offender or to support a safeguarding issue such as where we are concerned that you or someone else is at risk of harm. We will share information in an attempt to keep you or someone else safe, this might mean us contacting other health professionals, a crisis service, or the police.

Further information about this can be found in our Privacy Notice on our website. View our privacy policy.

Our Privacy Notice will advise you of whom we share information with, how long we keep your information for and what your legal rights are in respect of your data. Alternatively, you can contact our Data Protection Officer for further information at: The Retreat Clinics, Tuke Centre, 28 Green Dykes Lane YO10 3HH or email us at:

All information is retained in accordance with our corporate retention guidelines.


By submitting this form to The Retreat Clinics, you agree that the information you have provided is complete and true. You agree that:

  • You are aged 18 years or older.
  • You understand our terms of service, including our Data Protection statement, our cancellation policy, payment policy and refund policy. All of which are a condition of your service and agreement with us and can be found on our website
  • All information about you will be shared with our therapists to allow them to provide a service to you.
  • You can withdraw from the service/agreement at any time; however, charges will still apply to all booked sessions as per our cancellation policy.

All information in this form will be treated as strictly confidential.

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Help in A Crisis

There are many things that can make us feel low or hopeless and these feelings can come and go but it is important to take them seriously.

If you are having thoughts of suicide, are harming yourself or have thoughts about self-harm it is important to tell someone.

These thoughts and feelings can be complex, frightening, and confusing but you do not have to struggle alone.

Whilst The Retreat Clinics is not able to provide crisis services, if you feel unable to cope or keep yourself safe, please contact your GP immediately, or contact an organisation who specialises in crisis support. We have listed some organisations below who may be able to help you.

NHS Foundation Trust – all people of all ages

Website: Mental Health Helpline for Urgent Help - NHS (
Available 24 hours

Mental Health Innovations - support by text message

Mental health support by text message
You can text "SHOUT" to 85258 for free from all major UK mobile networks. You'll then be connected to a volunteer for an anonymous conversation by text message. This is a free, confidential, 24/7 text messaging mental health support service.

Samaritans – all people of all ages

Call: 116 123
Available 24-hour
Area: UK Nationally

Campaign Against Living Miserably (CALM) - Men

Call: 0800 58 58 58
Available 5pm to midnight every day – Cover National
Area: UK Nationally

Papyrus - people under the age of 35

Call: 0800 068 41 41
Text: 07860 039967
Available Monday to Friday 9am to 10pm, weekends and bank holidays 2pm to 10pm
Area: UK Nationally

Childline – people under the age of 19

Call: 0800 11 11
Online chat:
Available 24-hour
Area: UK Nationally