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

Personal Details

GP Details

Further Information

Characters remaining:
Please complete the captcha