Self Referral Form

Your confidentiality is important to us. This information will be submitted via a secure connection and we have taken all necessary steps to ensure your information is as safe and protected as possible.

Please complete this registration form as fully and honestly as possible.

As we want everyone to be able to access our service, if you are having difficulty completing this form don't hesitate to call us on 04 386 3861 or email us at


Our service is 100% confidential – we will not disclose any information to anyone without your consent.

All information you provide to us or that we record during the course of your treatment will be stored in a secure cloud-based platform. We do not keep physical records.

If you would like us to be able to provide anyone with your personal information or appointment times, please list them below.

You consent to Anxiety Specialists providing the people listed below with updates regarding treatment and acknowledge that Anxiety Specialists will not be able to provide any information to any individual whom you have not given consent for.

Please inform us if there are any changes in relationships which require an individual to be removed from or added to this list.

A treatment summary can be provided to your GP on request.