Therapy referral form

Please note: Our therapy services are for Anxiety UK members only.

Once you have joined Anxiety UK, please follow the steps below.

Complete the ‘therapy referral form’ -making sure you have to hand:

Proof of your total household income (PDFs, photo files or digital documents)
GP information

If you encounter any problem uploading your documents, you can also email them to us directly.

Please be aware that before an Anxiety UK Approved Therapist is allocated to you, you will need to pay for an initial number of sessions in advance. Once you have submitted your therapy referral form, our team will review the information provided and contact you by email to confirm these payments. It is important that you have read our terms and conditions and FAQs before applying for therapy to avoid any delay or confusion in processing your application.

Therapy referral form
If you are having difficulty filling in this form and need assistance, please call 0161 226 7727. Please note that our admin line operates 12-1pm Monday to Friday excluding Bank Holidays
Membership - are you a member of Anxiety UK?*
- Yes
- No
Our therapy services are for members only: join here.
Have you accessed talking therapy previously?*
- Yes through Anxiety UK
- Yes through other providers
- No

Talking therapies that are approved by the National Institute for Health and Care Excellence (NICE) and available through Anxiety UK for different anxiety conditions are listed below. For a full list of NICE recommended treatments, please see - https://www.anxietyuk.org.uk/get-help/types-of-therapy/

Anxiety/Depression type	NICE recommended therapy available through Anxiety UK
Generalised Anxiety Disorder (GAD) and panic in adults with or without Agoraphobia	Cognitive Behavioural Therapy (CBT)
	(CG113)
Panic Disorder	CBT (CG113)
Social Anxiety disorder in adults	CBT (CG159)
Social Anxiety disorder in children	CBT (CG159)
Post-traumatic stress disorder in adults	Individual trauma-focused CBT
	EMDR
	(NG116)
Post-traumatic stress disorder in children and young people	Trauma focused CBT for age 7 to 17 years
	EMDR for age 7-17 years
	(NG116)
Obsessive Compulsive Disorder (OCD) and Body Dysmorphic Disorder (BDD) in adults (other symptoms that come under OCD treatment are Trichotillomania and hoarding)	CBT (CG31)
OCD and BDD in children	CBT (CG31)
Irritable Bowel Syndrome (IBS) in adults	CBT
	Hypnotherapy and/or psychological therapy
	(CG61 & QS114)
Depression in adults (including Seasonal Affective Disorder)	CBT
	Counselling
	(CG90)
Depression in children	CBT (NG134)
Antenatal & postnatal mental health (depression and/or anxiety)	Follow guidelines for Depression
	(CG192)
Phobias	Counselling
	CBT
	Mindfulness (Guidance from https://www.nhs.uk/mental-health/conditions/phobias/treatment/)

Talking therapies that are approved by the National Institute for Health and Care Excellence (NICE) and available through Anxiety UK for different anxiety conditions are listed below. To access the a full list of NICE recommended treatments, please see here.
Please see our Privacy Notice for more information on how we process your personal data.
Disclaimer:*
- Yes
I have read and understood the therapy types that NICE recommend for anxiety and depression (as detailed above) and understand that if I select a non-NICE approved therapy, my Anxiety UK Approved Therapist will discuss this at my first therapy session, to ensure that the option chosen is appropriate.
Have you used our TherapGuide tool to help you decide which type of talking therapy you might be best suited to?*
- Yes
- No
If you are unsure as to which therapy type you might be best suited to, please try our handy TherapGuide tool here www.anxietyuk.org.uk/therapguide/ or call our helpline on 03444 775 774 and we can talk you through the various options that are available. It is recommended that only one form of psychological therapy is undertaken at one time. *
Please select the type of therapy you would like to access:*
- Counselling
- CBT
- Clinical Hypnotherapy
- CFT (Compassion Focused Therapy)
- **(Temporarily unavailable - do not select)** EMDR
*PLEASE NOTE - Our waiting list for EMDR is temporarily closed meaning we are not accepting any new referrals. The average number of sessions is 6-15 for CBT and Counselling. For Clinical Hypnotherapy and CFT, the average number of sessions is 4-6. For EMDR the average number of sessions is 8-12. Some Anxiety UK Approved Therapists are in training/have qualified on courses that lead to a dual qualification in REBT and CBT. Upon receiving a CBT referral, such Anxiety UK Approved Therapists may choose to follow either a hybrid (CBT/REBT) or sole CBT or REBT approach when supporting Anxiety UK clients.
Which form of therapy do you require?
- Online
- Phone (excluding EMDR & clinical hypnotherapy)
- Face-to-face
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Which form of therapy do you require?
- Webcam
- Face-to-face
Please specify the location in which you would like to be seen:*
Location 1 Location 2 Location 3
Please check location availability here.

If you are able to travel to more than one location, please list your top three preferences. Due to high demand we cannot always ensure referrals to your first preference, in which event Anxiety UK will refer you to your second or third preference.
If face-to-face therapy is not available in your selected location, would you consider phone or online?*
- Yes
- No
Therapist gender preference (Subject to availability):*
- Male
- Female
- No preference
How would you prefer your allocated therapist to make initial contact?*
- Home phone
- Mobile phone
- Text message
- Email
Is your referral request associated in any way with counselling required in relation to adoption?
- Yes
- No
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Have you accessed our Digital Online Therapy Service?
- Yes
- No
(http://anxietyuk.org.uk/dots)
Please provide details if you would like to request the same therapist you accessed through DOTS.
Your Details
Name*
First Last
Date of Birth:*
You must be over 18 years of age to access therapy with Anxiety UK
Email Address:*
Enter email Confirm Email

Please note: choosing to be contacted by email rather than via post or telephone will allow for quicker communication.
Address*
Street Address Address Line 2 City ZIP / Postal Code
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Daytime Telephone Number:*
Contact number:*

Please note it is essential that we are able to contact you by telephone.
Is it acceptable for us to leave a message on your answering machine?*
- Yes
- No
Is it acceptable for us to leave a message with someone answering your phone?*
- Yes
- No
Emergency Contact name:*
Emergency Contact phone number:*

Please note: we need details (name and number) for an emergency contact so we and your therapist know who to call in the event they need to at any time.
GP's Name*
First Last
GP's Address*
Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country
GP's Telephone Number:*
GP's email address:

Providing an email contact for your GP is not essential, but may speed up the process should we need to contact them prior to you starting therapy.
Have you accessed any mental health support services within the last 3 years? (e.g. crisis services/home treatment team, psychiatrist, community mental health team, social worker)*
- Yes
- No
Please give details:*
Including contact name, postal and email address and the contact telephone number of service or practitioner, plus the dates during which the service was accessed
Important: We may ask you to gain approval from your GP/other relevant professionals involved in your care, prior to starting/during therapy, if you disclose information that results in needing approval for consent to begin/continue therapy, including, but not limited to, feelings of suicidality and/or self-harm, taking specific prescribed medication(s), existence of specific physical or mental health issues, are under/have been under recent care of a mental health crisis service/secondary care mental health team. In most cases, this would be discussed with you before contact is made, however, if issues of safety arise, this may not always be possible. Until consent is received by your GP/other relevant professionals involved in your care, therapy will not begin/will be put on hold.
Your Health
Please give brief details of why you wish to access Anxiety UK therapy service including any symptoms experienced:*
Do you have any physical health issues or long-term health conditions?*
- Yes
- No
Please give details:*
Do you experience derealisation or depersonalisation?*
- Yes
- No
Please see here for more information
Do you have someone supportive who you can talk to?*
- Yes
- No
Are you currently in receipt of any other form of therapy/support?*
- Yes
- No
Please give details:
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Are you currently seeing any other mental health professional at present (e.g. psychologist/psychiatrist/counsellor)?*
- Yes
- No
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Please give details:*
Are you currently taking any prescribed psychiatric medication (e.g. anti-depressants)?*
- Yes
- No
Please give details:*
Including medication prescribed and dosage.
Do you have any substance use difficulties? (alcohol, drugs, use of non-prescribed/prescribed medication etc.)*
- Yes
- No
Please give details:*
Have you had thoughts of suicide within the past month?*
- Yes
- No
Please select, on a scale of 1-10, how intense these thoughts have been?
1 = fleeting thoughts of not wanting to be here; 10 = I have a plan and the will to carry out my thoughts.
Do you have a visual or hearing impairment that Anxiety UK/your Approved Therapist need to be aware of?*
- Yes
- No
Please give details:*
Do you need someone help you read letters and information leaflets?*
e.g. a family member, friend or professional.
- Yes
- Sometimes
- No
Please give details:*
How often do you have problems filling out questionnaires by yourself?*
- Always
- Sometimes
- Never
Do problems with numbers make it difficult for you to manage day-to-day activities such as paying bills and reading timetables?*
- Always
- Sometimes
- Never
Therapy Fees
Fee Category/Eligibility Criteria*
- Tier 1: Total household income/individuals with savings under £10,000 or in receipt of following benefits: Personal Independence Payment (PIP) JSA, Income support, ESA or Carers and Disability Allowance, or individuals living on a State Pension only. Also students living independently in full time education
- Tier 2: Total household income and/or savings of between £10,000 and £25,000.
- Tier 3: Total household income and/or savings of between £25,000 and £40,000.
- Tier 4: Total household income and/or savings of between £40,000 and £50,000.
- Tier 5: Total household income over £50,000+
Please select tier, attaching proof if you are claiming for any tier below 5. Applications cannot be progressed without this evidence. For EMDR, session length is 60-90 minutes. For 90-minute sessions, fees will be charged proportionately.
Please upload proof of income so that we can verify your eligibility to the selected tier:*
Drop files here or

Accepted file types: jpg, pdf, png, docx, doc, Max. file size: 15 MB.
Proof of income could include one of the following - P60, wage slip, annual tax return, or a letter confirming you are eligible for benefits from the DWP or similar government agency.

If you are applying for student fees, please attach a copy of your student ID and tenancy agreement to show you are living independently.
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I declare that I have taken into account all household income and savings when selecting my eligibility for a Therapy Services tier.*
- Yes
- No
Tick to consent
I have read and understood Anxiety UK’s Terms and Conditions and Privacy notice.
I consent for Anxiety UK to correspond with me and my Anxiety UK Approved Therapist by email
I have attached proof of eligibility for discounted therapy fees at the tier claimed (if relevant)
I have provided the name and contact details of my GP/other professionals involved in my care
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Data Security
If you have requested that Anxiety UK correspond with you by e-mail, which will require e-mailing your personal data outside of our own IT network. We are required to inform you there is the risk of data loss when e-mailing outside our IT network, therefore we require written confirmation (this can be an e-mail response sent to [email protected]) that you accept this risk.
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Email Correspondence*
- I give consent for Anxiety UK to correspond with me in relation to my Therapy Referral by email. I acknowledge that this may entail the risk of data loss and understand that Anxiety UK will store information safely in files and IT systems and that I can withdraw my consent for them to hold my information at any time by written notification.
- I do not give consent for Anxiety UK to correspond with me in relation to my Therapy Referral by email.
We are happy to accept encrypted emails and documents. You can then call to provide the password over the phone. If you would like details on how to encrypt this document please contact [email protected] and the details will be passed over to you.

Terms and conditions are available here or via the above email address.
Terms and Conditions
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I have read and understand all aspects of my therapy application with Anxiety UK, including the Charity’s payment terms and refunds policy and Anxiety UK’s Terms and Conditions*
- Yes
- No
Equality Monitoring (optional)
Anxiety UK is committed to providing services that promote equality and diversity. Please complete the below:
Age
- 18-25
- 26-35
- 36-45
- 46-55
- 56-65
- 65+
- Prefer not to say
Gender
- Male
- Female
- Other
- Prefer not to say
Ethnic Origin: White
- British
- Irish
- Other
- Prefer not to say
Ethnic Origin: Asian or Asian British
- Indian
- Pakistani
- Bangladeshi
- Chinese
- Other
- Prefer not to say
Ethnic Origin: Black or Black British
- African
- Carribean
- Other
- Prefer not to say
Ethnic Origin: Other
Please specify your ethnic origin here, if not listed.
Religion or Belief
- Atheism
- Agnosticism
- Buddhism
- Christianity
- Hinduism
- Islam
- Judaism
- Sikhism
- Other
- Prefer not to say
Religion or Belief: Other
Please specify your religion or belief here, if not listed.
Sexual Orientation
- Heterosexual
- Lesbian
- Gay
- Bisexual
- Other
- Prefer not to say
Sexual Orientation: Other
Please specify your sexual orientation here, if not listed.
Where did you hear about Anxiety UK?*
ReQol Scoring
For each of the following statements, please tick one box that best describes your thoughts, feelings and activities over the last week.
I found it difficult to get started with everyday tasks*
- None of the time
- Only occasionally
- Sometimes
- Often
- Most or all of the time
I felt able to trust others*
- None of the time
- Only occasionally
- Sometimes
- Often
- Most or all of the time
I felt unable to cope*
- None of the time
- Only occasionally
- Sometimes
- Often
- Most or all of the time
I could do the things I wanted to do*
- None of the time
- Only occasionally
- Sometimes
- Often
- Most or all of the time
I felt happy*
- None of the time
- Only occasionally
- Sometimes
- Often
- Most or all of the time
I thought my life was not worth living*
- None of the time
- Only occasionally
- Sometimes
- Often
- Most or all of the time
I enjoyed what I did*
- None of the time
- Only occasionally
- Sometimes
- Often
- Most or all of the time
I felt hopeful about my future*
- None of the time
- Only occasionally
- Sometimes
- Often
- Most or all of the time
I felt lonely*
- None of the time
- Only occasionally
- Sometimes
- Often
- Most or all of the time
I felt confident in myself*
- None of the time
- Only occasionally
- Sometimes
- Often
- Most or all of the time
Please describe your physical health (problems with pain, mobility, difficulties caring for yourself or feeling physically unwell) over the last week*
- No problems
- Slight problems
- Moderate problems
- Severe problems
- Very severe problems
Consent*
I agree that you may use the above information for equality monitoring purposes, I understand that the data will be anonymised shortly after receipt.
Comments
This field is for validation purposes and should be left unchanged.

About us

Anxiety UK is a national registered charity formed in 1970, by Katharine and Harold Fisher, for those affected by anxiety, stress and anxiety based depression.

To read more please click here.

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Let us know how we’re doing by leaving a review – your feedback is really important to our small team.

Contact us

Anxiety UK, Nunes House, 447 Chester Road, Manchester M16 9HA

Support channel details:

(10.30am-4.30pm, M-F)

Helpline: 03444 775 774 Text: 07537 416905

Admin line: 0161 226 7727 (12pm-1pm, M-F) or: [email protected]

Press/media enquiries: [email protected]

AnxietyUK

4.5

Based on 81 reviews

review us on

Caroline Frankau

18:49 07 Mar 23

Joining Anxiety UK has had a very positive impact on my health and well-being. I thoroughly recommend their services.

Jonathan Beever

11:25 10 Oct 22

Niamh Shepherd gave an interactive online talk at my work today! it was one of the best Anxiety presentations i have seen and very well delivered, From my colleagues and I, thank you!

Natalie Dunning

10:43 07 Oct 22

Used the service for a vulnerable relative. The therapist appointments were a nightmare and were incorrectly set up via Anxiety UK, he never got the perks or discounts for the mindfulness app and everyone I spoke to was either completely clueless and when I spoke to the manager he was so rude that I worried for the vulnerable people using the service!

nat

17:31 26 Sep 22

I had my CBT through Anxiety UK and it has been a really positive experience treating my generalised anxiety disorder. The Anxiety UK team is very professional and helpful and I was actually recommended by a friend who also had a positive experience with their CBT. I would definitely use Anxiety UK again if I needed to!

sophie jorgensen-rideout

11:35 22 Sep 22

AnxietyUK has been so helpful to me - I joined to access affordable therapy, though I was worried there might be a long wait list. This was absolutely not the case, and I was assigned a therapist super quickly! They were also super helpful when unfortunately our schedules didn't align, and I was matched with a therapist with availability that matched mine. I really recommend AnxietyUK to everyone- they also have fantastic group resources and I think it's really really helpful, especially if you can't afford private therapy and the wait lists in your area are too long.

Susie Kocher

14:31 20 Aug 22

I found the therapy I received through Anxiety UK a crucial and affordable form of support during a very difficult time.For this I am forever grateful and will without a doubt use their services if needed again in the future.Thank you so much.

Joan Treloggan

12:28 03 Aug 22

Felt I was being listened to and felt I belonged. It was very reassuring. Unfortunately I am very deaf and missed most of the sharing. Is it possible to have subtitles please. A very sincere thank you for being there for me. What swift service you give.

Henry Brook

09:55 18 Jun 22

Very nice to know this support is out there as quite often hard to actually get an opportunity to speak to someone in person these days. Had my first session last week and so far so good. Very happy with the way things are going so far and also pleased with how smoothly it was set up and assessed as to what I was after and a service that fitted around my work and life balance.

Richard Evans

04:12 22 Mar 22

Through a period of some significant challenge, the services offered by Anxiety UK has been fantastic, and whilst there is a long road head, progress is positive and forward.I’m extraordinarily grateful for the help and support during a challenging time, both to the Anxiety UK and my Professional Institute, The Chartered Institute of Building and their respected benevolent fund.I'm about a third the way through a 16-week program and the benefits and rewards are already coming through.Thanks again, eternal appreciation.Rich

Greg

16:56 18 Mar 22

Speedy, understanding and professional. If you're struggling, don't be ashamed to seek out the help you need.

Avis Gough

20:57 15 Feb 22

Found it reassuring I'm not the only person struggling or that I'm doing things wrong

Margaret Allan

17:11 01 Feb 22

I can't recommend Anxiety UK enough as they were a godsend to me while I waited on my psychology Appointment with NHS which took over a year.During this time I used most of the resources that can be found on the Anxiety UK website. One of the resources I used was the counselling and Cognitive Behavioural Therapy. I paid for this but my fee was really small and worth every penny. Therapists are all qualified Healthcare Professionals who give up their time to help.Personally I feel Anxiety UK offers a fantastic service which fills that much needed gap between being referred to NHS and your actual appointment time which nowadays due to Covid can be up to a year in waiting time.Please don't wait and suffer just visit the Anxiety UK website and see for yourself !!

Tori Fenton

20:19 30 Nov 21

Amazing experience! Everyone was so welcoming and non judgemental. It was really reassuring to know that I’m not on my own. A lovely bunch of people, very empathetic and willing to share their experiences as well as their own coping mechanisms.

Manisha Gosar

14:36 13 Nov 21

Very approachable, helpful and value for money

Therapy referral form

Please note: Our therapy services are for Anxiety UK members only.