Self Referral Form

Welcome to Big White Wall, you’ve taken a big step towards feeling better.

We want to give you a little more information about what will happen when you complete the below form and begin online therapy.

  • We will receive your completed form and you’ll receive an email from ourselves to complete your registration to Big White Wall, this will involve activating your account.
  • You can then log onto Big White Wall and can use our booking system to choose your therapist and availability under ‘LiveTherapy’
  • If you choose not to book your therapy using our booking system, you will receive a call from one of our team asking for your availability.
  • You can then start your therapy sessions, often within the first week of completing the form.

If you have any questions please contact theteam@bigwhitewall.com.

Personal Details








GP Details


Further Information


Characters remaining:
Please complete the captcha