Mood and Anxiety Self-Assessment
ADHD symptom checker

Our Expertise
Depression sympton checker

Our Expertise
Depression sympton checker

Levitas Group — Referral Form

Complete this referral for wellbeing/psychological support. Fields marked * are required. Data stays in your browser unless you submit to a backend.

1. Personal details

First name *

Last name *

Date of birth *

NHS number (optional)

Gender *

Preferred name (if different)

2. Contact information

Phone number *

We will use this to contact you if required.

Email address *

Address *

Postcode *

Preferred contact method

3. GP / Doctor details

GP name *

Practice name *

Practice address *

Practice phone

4. About you

Employment status

Ethnicity

Preferred language

Who do you live with?

5. Current difficulties

Please describe the main problems or reasons for referral *

When did these problems start?

Have you had similar issues before?

6. Impact on daily life

How are these difficulties affecting your daily life? (tick those that apply)

Sleep Appetite Work/study Relationships Substance use Daily activities

How would you rate your overall functioning (1 low — 10 high)?

This helps us understand urgency and impact.

7. Risk assessment

Do you currently have thoughts of harming yourself or ending your life? *

No Yes Not sure

If yes / unsure, please give details (when, intent, plans, support)

Are you currently at risk of harming others?

No Yes

Any history of self-harm or suicide attempts?

No Yes

8. Medication / current support

Are you currently prescribed any medications? (include dosages)

Are you currently receiving support from other services?

No Yes

If yes, please give details (service, contact, clinician)

9. Accessibility & contact preferences

Do you need an interpreter?

No Yes

Please specify language in the box below.

Do you have any hearing or visual needs?

Any other preferences for contact or appointments?

10. Consent & declaration

I confirm that the information I have provided is accurate to the best of my knowledge, and I consent to Levitas Group contacting my GP and other services as appropriate.

Typed signature (full name) *

Date *

11. Submit

Please review the form carefully before submitting. Once submitted, you will see a confirmation and have the option to download a PDF.

Please complete required fields highlighted above.

Thank you — referral submitted

We have received your referral. A member of the Levitas wellbeing team will review and contact you according to your preferred contact method.

Levitas Group — Confidential referral form. For emergencies, call local emergency services or crisis lines immediately.

Our Locations

LEVITAS GROUP HEAD OFFICE

21 Woodstock Street
London
W1C 2AN

0207 459 4254

Website

LEVITAS CLINIC GUILDFORD

116 London Road
Guildford
GU1 1TN

01483 452 555

Website

LEVITAS CLINIC
ESHER

8 High Street
Esher
KT10 9RT

01372 642 555

Website

LEVITAS CLINIC LONDON

20 Woodstock Street
London
W1C 2AN

0207 459 4854

Website

IAAGSW International Association of Aesthetic Gynaecology and Sexual Wellbeing

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Mood and Anxiety Self-Assessment
ADHD symptom checker

Our Expertise

Our Expertise

1. Personal details

2. Contact information

3. GP / Doctor details

4. About you

5. Current difficulties

6. Impact on daily life

7. Risk assessment

8. Medication / current support

9. Accessibility & contact preferences

10. Consent & declaration

11. Submit

Thank you — referral submitted