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“It was such a relief when I made the decision to get help –it felt as though I had some control over my life back”

Merton Uplift Self Referral Form

Brief questions to help understand the support that would suit you.

Please let us know if you want support to complete the form.

Confidentiality : Just so you know – if in working with us we become aware that you or a 3rd party is at risk then we will need to inform relevant agencies to ensure that the right support is provided.

Contact Details

Your Support: Who supports you?

About You - This helps us to check if our service is reaching out to wide ranging people

Please specify so we can be mindful of your needs in supporting you.
(Please tell us about any physical disabilities such as visual or hearing impairment)

About Us: The services we provide include:

*Wellbeing – practical support to reduce stress (time mgt, balanced life) or helping you to access activities/ services that improve your wellbeing (vocational, social, leisure or active opportunities, support groups, housing)

*Psychological Therapies – various individual and group therapies for depression and anxiety based difficulties

*Psychiatric Assessments - for those with more serious mental health difficulties

Your Support Needs

(you can select both)
(Please add as much detail as possible so we can ensure you access the best support)
(e.g. physical health issues, sign language, travel, concerns regarding your safety, interpreter [specify preferred language], relative/friend speak on your behalf – please provide the name)
(You can choose more than one)


  • Recovery College
  • Imagine Independence
  • Sutton Age UK
  • Off the Record
  • Off the Record