Please complete the form below to refer a person to GMCH Limited

Referrers Name Referrers Name First Last
GDPR - By submitting your enquiry you are consenting to GMCH Limited storing your submitted information so we can respond to your enquiry.
Your Relationship to the Referee
Phone
Email
Name of Referee Name of Referee First Last
Date of Birth (if known) Date of Birth (if known) / MM / DD YYYY

PLEASE NOTE: we are unable to offer care to anyone under the age of 18.
Is this referral urgent in its nature?

Is this referral urgent in its nature? Yes No
If you are aware of any clinical diagnosis, please select any/all that apply.

If you are aware of any clinical diagnosis, please select any/all that apply. Major Depression Persistent Depressive Disorder Bipolar Disorder Postpartum Depression Premenstrual Dysphoric Disorder Generalized Anxiety Disorder Obsessive-Compulsive Disorder Panic Disorder Phobias Social Anxiety Anorexia Nervosa Bulimia Binge Eating Post-Traumatic Stress Disorder Acute Stress Disorder Kleptomania Pyromania Intermittent Explosive Disorder Schizophrenia Schizoaffective Disorder Brief Psychotic Disorder Narcissistic personality Disorder Borderline Personality Disorder Avoidant Personality Disorder Paranoid Personality Disorder Dependent Personality Disorder Histrionic Personality Disorder Obsessive-Compulsive Personality Disorder Antisocial Personality Disorder Addiction and Substance Abuse Disorders Other Other