Stage 1 - Basic Information

What is your Registered GP Surgery?*

The italk self-referral service is available to patients of the GP Surgeries in all our current localities; Eastleigh, Havant, Gosport, New Forest and Test Valley (see GP Surgery list below). If your Surgery is not within these listed localities, it means we would not be able to offer you treatment. Your GP should have resources to direct you to other available services in your area.

What is the name of your Registered GP at this Surgery?*

Please call your GP Surgery if you do not know this as every patient will be linked to a Registered GP.

Do you consent for your information to be kept on our secure patient management system?* Our Security Statement can be seen here

Please note that we use our system to record notes and book your appointments and we would not be able to offer you treatment without consent to do this.

Do you consent for your GP as listed above to be notified of your self-referral to italk?*

Please be aware that it’s our policy to keep your GP informed with current treatment you are receiving and we would require your consent to do this.

Are you currently being seen by any psychological therapist or service?*

For example; Counselling, Community Mental Health Team, Crisis team, Therapist, Psychologist. Please note we will not be able to offer you treatment with the italk service alongside receiving psychological therapy from other psychological services / professionals.