Referral – Canopi

Canopi provides a free and confidential mental health support service for NHS and social care staff in Wales.

Please note, we are not an emergency service. If you need help immediately, click here.

Self-Referral form

Need to talk? If you would like to access support through Canopi, fill out the form below and we will email you within one working day.

Please note: Canopi will not usually accept self-referrals from individuals currently receiving, about to start, or recently finished psychological treatment or therapy elsewhere. In such cases, we recommend discussing your reasons for seeking additional support with your current care provider or GP.

Referral

If you feel that you may be experiencing a crisis, please dial 999 or visit our Help in a crisis page.

I do not think that I need emergency help for my mental health and am able to keep myself and others safe.*

Before submitting your referral, please confirm the following:

I, as the individual wish to receive mental health support from Canopi and confirm that I am aged 18 years or over.

I am not currently receiving, about to start, or recently finished psychological treatment or therapy from another care provider.*

I have not accessed Canopi’s services before/ it has been at least 3 years since I had a course of therapy with Canopi.

Your full name / Eich enw llawn *

Email / Ebost *

Please confirm your email address again in the box below. This must be an address which you have regular access to.

Confirm Email / Ebost *

Phone / Ffôn *

Are you employed to work in the NHS or in social care in Wales? / Ydych chi’n cael eich cyflogi i weithio yn y GIG neu ym maes gofal cymdeithasol yng Nghymru? Are you employed to work in the NHS or in social care in Wales? / Ydych chi'n cael eich cyflogi i weithio yn y GIG neu ym maes gofal cymdeithasol yng Nghymru?

Employment organisation / Sefydliad cyflogaeth

This information will be used to determine your eligibility for the service, and your employer will NOT be notified.

Profession or job role / proffesiwn neu swydd *

Have you used the service before? If so, who was your Wellbeing Ally or Therapist? / A ydych chi wedi defnyddio’r gwasanaeth o’r blaen? Os do, pwy oedd eich neu Cymorth Cynghreiriaid Lles neu Therapydd?

Where did you hear about the service? / Ble clywsoch chi am y gwasanaeth?

If you are human, leave this field blank.

What happens next?

Once you have completed the referral form, you will be emailed within one working day to confirm your details. You will also be asked to complete a short form which asks how you have been feeling recently.
Once we receive this from you, you will be sent a link to book an appointment with a doctor advisor.
At the time of your confirmed appointment, the Doctor Advisor will call you from a withheld number. Please check your junk mail so that our emails are not missed.