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 Manor Clinic, the referrer and patient, is efficient, accurate and safe. To ensure you successfully receive electronic correspondence from Manor Clinic, please add ManorClinic.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, if your request is of an urgent nature, or you would prefer to speak directly to a member of our dedicated enquiries team, please call: 0800 840 3219

Please complete the following information

Patient details

Patient Name

Date of birth

Please confirm contact details of your patient to allow Life Works 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

Please click here for our 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.