Request an Appointment for Mental Health Support

Do you need help with your mental health? If you are feeling low, anxious, depressed or just need someone to talk to, please complete this form and we will arrange an appointment to speak to our psychological well-being practitioner. You must be 18+.

PLEASE NOTE: THIS FORM IS NOT FOR URGENT MENTAL HEALTH PROBLEMS. PLEASE CALL THE SURGERY OR ATTEND A+E STRAIGHT AWAY IF YOU ARE CONSIDERING HARMING YOURSELF.

Full Name

Date of Birth

Address

Contact Number

What type of appointment would you prefer?

Phone Assessment
Face to Face

Are you happy to be sent an appointment via text with your appointment details?

Yes

I consent to my information being used for the purposes described above and wish to submit this online form to Nelson Surgery • Bryncelyn, Nelson, Treharris, CF46 6HL.

Yes