Steps2Wellbeing Southampton - Self Referral Form

If you provide an email address we will send a confirmation email.

After we receive this online referral, we may contact you via email, post or telephone. Please only fill in the relevant boxes if you consent to be contacted via that method.

Please note that we will NOT accept referrals for under 18s

Gender *
Please state GP Practice below. If you are not registered with a Southampton GP surgery, you will not be eligible for our service.
Are you pregnant and/or have a child under two years old?
Are you a member of armed forces/family member or Veteran *
Do you have Diabetes? *
Which type?
Do you suffer from chronic pain / Fibromyalgia/ Chronic back pain / MSK? *
Please tick all that apply
Do you suffer from a respiratory condition? *
Please tick all that apply
Do you suffer from a heart condition or have you had a stroke? *
Please tick all that apply
If you would like us to contact you via email, please provide an email address below.
I agree to a message being left by
I agree to a message being left by
Are you completing this form on behalf of a friend / family member? (We can only accept referrals where the patient is aware) *
This Fair Processing Statement tells you how we use your information. Please read before submitting the form.
After clicking on "Submit" you will be redirected to the Steps2Wellbeing website. If you receive an error after pressing submit on this form, please contact