Make a referral

Our online referral form is simple, safe, and secure. All patient details will be processed in the strictest confidence. A unique reference number is generated for each enquiry which ensures subsequent communication between Priory, the referrer and patient, is efficient, accurate and safe. To ensure you successfully receive electronic correspondence from Priory, please add Priory.Referral@nhs.net to your safe list or address book.

All patient details will remain confidential and will only be used for administrative purposes to help us assist with your enquiry. Any information you provide is encrypted and submitted over a secure connection and cannot be viewed by anyone else on the web. Please complete the form below and your enquiry will be dealt with promptly. Alternatively, you can email us, or call our dedicated GP enquiries line on 0800 090 1354

You can also download a copy of the referral form, which can be completed and scanned or faxed to Priory: PDF copy / Word copy

Please complete the following information

Patient details

Patient Name

Date of birth

Please confirm contact details of your patient to allow Priory to make contact regarding their appointment or treatment options. Patient address

Telephone number

Email address

GP contact details

Name of referring GP

Practice address

Practice telephone number

Referring GP contact email address

Referral details

Provisional diagnosis or condition if known

Reason for referral (please include supplementary information relating to patient e.g. current symptoms, relevant history, known triggers, precipitating factors, protective factors, dual diagnosis)

Risk factors associated with patient

Supplementary patient details

Please include any relevant psychiatric reports, assessments or completed questionnaires e.g. PHQ-9 or GAD-7

Past medical history

Medication

Allergies and family history

Investigations

Additional supporting information e.g. physical health issues

Recent consultations

Click here for full privacy notice

By clicking send you agree to us using the information provided to manage your enquiry. If enquiring on behalf of someone else, you must obtain their consent to providing us with their information.