Supported Self Help: Self-Referral Form

Supported Self Help: Self Referral

‘Supported Self Help’ is Derbyshire Mind’s early intervention guided self help programme that empowers you to improve your own mental health using CBT based tools, supported by our friendly practitioners.

This programme is designed to provide support for people across Derbyshire who may be experiencing mild-moderate mental health symptoms, who are not already under the care of any other mental health services such as CMHT or talking therapy. Supported Self-Help is not suitable for people in crisis, is it is not a counselling service, and it is only for those aged 18 and over.

As soon as we receive this referral form, we review what you have told us and will then call you, typically within 3 working days, to discuss in more detail what Supported Self-Help is and isn't, and then together we will figure out if this is a service that is appropriate for you at this time.

Your Name(Required)
(This is the number we will call you on within around 3 working days to discuss this service and your referral.)
Your Date of Birth(Required)

This will help us determine if Supported Self Help is a good fit for your needs.
Which of these categories does this issue fit within?(Required)

The following questions might not all seem relevant to your support, however they can help us with sustaining our delivery of the Supported Self Help service. Your answers can help us apply for funding, help us make improvements to the service and also ensure we are reaching the people who most need the support. You can select "prefer not to say" for the questions, however we really appreciate it if you can take the time to share this information with us. For further information on how we use your data, please see our Privacy Statement on our website.
What is your gender?(Required)
Do you have a disability?(Required)

Please tick to confirm that you have read and understand the following important points:(Required)

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