Self-Referral Form for General Therapies Services

You can call us on 01904 412551 choose option 1 and we will complete your referral over the telephone

If you would prefer our form in print, large print, or in another language, please contact us on 01904 412551, choose option 1 and speak with one of our specialist administrators.

Please enter your details below

phone / email / post
If yes, please give details including names & contact details of professionals /Care Co-ordinator involved.
If yes, please provide some details, including an indication of how it helped you.
For example, any disabilities, weight, diet, use of drugs/alcohol or sleep.

We are asking the following three questions to make sure that we can care for you safely.

If we are concerned that you, or somebody else, is at risk of harm and our therapy services are not best placed to support you we may need to suggest alternative support to you and we may need to share information with other healthcare professionals in an attempt to keep you or somebody else safe.

If you are not funding the therapy yourself, please let us know who will be funding it

If another person or organisation is funding your therapy, please provide their full contact details

I give The Retreat my consent to contact this person about my referral


For the purposes of the General Data Protection Regulations 2016 (GDPR) / Data Protection, The Retreat York is the data controller for the collection, processing, sharing and storage of this data. All information collected in this form will be for the sole purpose of providing a clinical service to you and will only be passed to third parties who support us in the administration of this service or where we have your consent to do this.

However, we may have to break this confidentiality where we have a legal obligation to comply with the law for example. the information is required to detect a crime or apprehend an offender or to support a safeguarding issue such as where we are concerned that you or someone else is at risk of harm. We will share information in an attempt to keep you or someone else safe, this might mean us contacting other health professionals, a crisis service or the police.

Further information about this can be found in our Privacy Notice on our website at:

Our Privacy Notice will advise you of whom we share information with, how long we keep your information for and what your legal rights are in respect of your data. Alternatively, you can contact our Data Protection Officer for further information at: The Retreat York, 107 Heslington Road, York, Y010 5BN or email us at:

All information is retained in accordance with our corporate retention guidelines.


By submitting this form to The Retreat York, you agree that the information you have provided is complete and true. You agree that:

• You are aged 18 years or older.
• You understand our terms of service, including our Data Protection statement, our cancellation policy, payment policy and refund policy. All of which are a condition of your service and agreement with us.
• All information about you will be shared with our therapists to allow them to provide a service to you.
• You can withdraw from the service/agreement at any time; however, charges will still apply to all booked sessions as per our cancellation policy.

All information in this form will be treated as strictly confidential.

Important Message

There are many things that can make us feel low or hopeless and these feelings can come and go, but it’s important to take them seriously.

If you are having thoughts of suicide, are harming yourself or have thoughts about self-harm, it’s important to tell someone.

These thoughts and feelings can be complex, frightening and confusing, but you do not have to struggle alone.

Whilst The Retreat is not able to provide crisis services, if you feel unable to cope or keep yourself safe please contact one of the following organisations to get support right away.

Samaritans – for everyone
Call 116 123

Campaign Against Living Miserably (CALM) – for men
Call 0800 58 58 58 – 5pm to midnight every day
Visit the webchat page

Papyrus – for people under 35
Call 0800 068 41 41 – Monday to Friday 9am to 10pm, weekends and bank holidays 2pm to 10pm
Text 07860 039967

Contact The Retreat

General Enquiries?
Call 01904 412551

Out of Hours Contact?
Voicemail 01904 412551

Opening hours?

Our opening hours vary for different therapy services. View them here…

We are located at The Retreat, Heslington Rd, York, YO10 5BN

PLEASE NOTE – We have a limited number of parking spaces and at times this may mean you will have difficulty finding somewhere to park. Please call us ahead of your appointment if you have mobility difficulties which means that you require a parking space close to the Tuke Centre entrance or if you have specific access requirements.

Common  Questions

What is Online/Video Therapy?

Our online therapy service allows us to offer help and support to people not able to access our York-based service face-to-face. Online therapy is a developing area for counselling and psychotherapy, and is also known as webcam counselling, e-therapy, web therapy, internet therapy and distance therapy. This service allows you all the benefits of face-to-face sessions with a therapist, via your personal computer and from the comfort of your home. 

Our skilled counsellors, psychologists and therapists will listen to you in a non-judgmental way in a private, confidential setting. They can help you with your current difficulties, past experiences or anxieties about your future with the aim of helping you improve the quality of your life and relationships.

What is Post-Traumatic Stress Disorder?

Any one of us can experience something that we find traumatic. This could be something recent that has happened to us or it could be from our earlier years. Either way, around 30% of people who experience something traumatic go on to develop symptoms of Post-Traumatic Stress Disorder (PTSD). Traumatic events can vary widely, from road traffic or other accidents, involvement in military combat, near death experiences, or some form of abuse as a child or adult.

PTSD is a name given to a range of symptoms that someone may experience. Often, when we experience a situation that is traumatic, we may at first feel quite numb, but later experience symptoms such as:

  • Nightmares or frightening thoughts
  • Re-living the traumatic event, often termed ‘flashbacks’
  • Avoidance of reminders of the event and of talking about it
  • Irritability or outbursts of anger
  • Hyper vigilance and alertness to possible danger
  • Problems with concentration and memory.

These are all symptoms of PTSD and are usually very distressing to us.

What is Autism?

Autism is a lifelong developmental disability that affects how a person communicates with and relates to other people, and how they experience the world around them.

It is a spectrum condition, which means that, while all people with autism share certain difficulties, their condition will affect them in different ways.

Some people with autism can live relatively independent lives, but others may have accompanying learning disabilities and need a lifetime of specialist support.

What is Attention Deficit Hyperactivity Disorder (ADHD)?

Attention Deficit Hyperactivity Disorder (ADHD) is a group of behavioural symptoms that include:

  • Inattentiveness – most people with ADHD will have a short attention span and may be easily distracted.
  • Hyperactivity – there is likely to be some restlessness, fidgeting or overactivity. This can also lead to difficulties in sleeping and increased anxiety.
  • Impulsiveness – people with ADHD may do things without thought for the consequences, without very much reflection and without having a plan.

Some adults will have ADHD without it being diagnosed at a younger age. Those who are diagnosed at a young age are likely to continue to experience problems, though the symptoms might reduce.

What therapies do you offer?

We offer a range of individual and group therapies in line with NICE (National Institute for Health and Care Excellence) guidance. All of our therapists are highly trained, experienced and committed to continued professional development. Many therapists have training in more than one therapy modality, and are therefore in the best position to offer tailored, individualised therapy to meet your needs, drawing from the most up to date, evidence-based interventions.

Our therapies are usually delivered face to face, in relaxing therapy rooms. However if you are unable to come to The Retreat for your appointments, whatever the reason, we may be able to offer you an appointment via video link, using a secure platform called VSEE. 

How do I access the service?

All therapies are accessed via our Initial Therapies Assessment. 

To refer yourself to our general therapies service, or just to talk to us about whether we can help, please call us on 01904 412551.

Is the service confidential?

All our services are confidential, and our therapists and clinicians follow professional codes of conduct which include principles around confidentiality. This means we will not disclose information about you to a third party without your consent, unless we had significant concern for either your safety or the safety of someone else. We would make every attempt to discuss this with you if the situation arose.

Can I get involved in The Retreat?

We welcome representation from people who have finished their therapy or support within our services. There are a number of ways you can get involved, from joining us at information sharing events, helping us raise the profile of our services through the media, or consulting with us to help develop new service or recruit new staff. Please contact us for more information. 

Get in Touch. We Are Here To Help.

Let’s talk about mental health.
Our team of qualified therapists are here to help you

Heslington Rd, York, YO10 5BN

Call Us: 01904 412 551