Booking Therapeutic Support - Access Therapies Fife NHS

Therapeutic Support - Contact Form

Personal Details

Name(Required)

Title First name Surname

Date of birth(Required)

How would you like to be known?(Required)

What is your ethnicity?(Required)

Email(Required)

Enter Email Confirm Email

Phone(Required)

Address Details

Address(Required)

Street Address Address Line 2 City Postcode

Your GP Practice

Your GP Practice(Required)

Please provide more information regarding your out of area GP

Occupation Details

Job Role(Required)

Organisation(Required)

Employment Location(Required)

Please confirm your main work location / base

Background Information

1. What has brought you to seek psychological therapy at this time?(Required)

2. What are the main difficulties you’re experiencing?(Required)

(How are these challenges affecting your day-to-day life, relationships, work, or wellbeing? How long have you been feeling this way?)

3. What would you like to get out of therapy?(Required)

(What are you hoping will change or improve through therapy? What specific goals or areas would you like to work on?)

4. Have you had psychological therapy or mental health support in the past?(Required)

(If yes, please briefly describe what kind of support you received and whether it was helpful.)

How did you hear about us?

Before you submit this self-referral form, please take a moment to check your telephone contact details above as assessment appointments are offered by phone. Once your referral is received, it will be reviewed by a senior member of the clinical team. A member of the service will then make contact with you to follow up. Please be aware that that this call may come from a private number. You will receive an automated email response - if you do not receive this please contact the Service on 01383 565403

Name

This field is for validation purposes and should be left unchanged.