1. 1) Self referral form 
  2. Completed

Medic Support

Welcome to the Medic Support Self-Referral Form

Please complete the information below. It is important that you complete the required fields and read and accept the terms and conditions at the bottom of the form for your referral to be processed.

The reason for asking you to complete the referral form below is to enable us to assess your suitability for the service and direct you to the most appropriate help for your situation. All information you provide will be treated in strictest confidence and will not be shared outside of the service without your knowledge and consent.

Please note that Medic Support is not a crisis service. If you are in crisis or feel unsafe or at risk to yourself or others, then you should contact 111/999, your own GP or attend your nearest Emergency Department/A&E as soon as possible.

The Samaritans: 0161 236 8000 (local call charges apply) or 116 123 (free to call) can also be provide confidential support and are open 24 hours a day.

If you have any problems completing this form please email medic.support@oxfordhealth.nhs.uk

Please be aware that this page will time out after 40 minutes and your referral will not be submitted.

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https://www.oxfordhealth.nhs.uk/medic-support/offer/confidentiality/
Additional information
This information may help us provide the best care possible as well as monitor equality of access and inclusion. However, completing any of the fields below is optional.
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How can we help? (optional)
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If you are concerned with your own safety or the safety of another person, please contact your GP or the GP Out of Hours Service on 111
In an emergency Medic Support ServiceMedic Support Service (oxfordhealth.nhs.uk)
If you do not wish to provide further details at this stage, please go straight to Terms and Conditions and submit your referral.
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To process your referral, we need to ensure that you are aware of how we look after your records and obtain your consent to process your personal data. Please see our confidentiality policy for details. By accepting our terms and conditions you consent to us processing your personal data for the purpose of providing you with clinical care and/or signposting you to appropriate clinical care outside Medic Support.

Service provided by Oxford Health NHS Foundation Trust

Contact Email: medic.support@oxfordhealth.nhs.uk