Take Time Client Form 2023

Welcome to the Take Time service on-line self-referral form.

All information on this form is confidential to the Take Time service. This questionnaire is located on an encrypted secure server. Any answers that you provide on this form will also be encrypted.

Once you have completed the below form, you will be contacted by a member of the clinical team as soon as possible. We encourage you to attend the appointments offered given that HEEYH is supportive of doctor's and dentist's wellbeing along with appreciating the value of yourselves and the Take Time clinicians. 

Data ProtectionBefore completing the referral form, please ensure you read and understand the service Privacy Notice, which will inform you of how we will handle your information and set out your rights under the Data Protection Act (2018) in relation to the processing of your information by our service.  

The full policy can be read here: 


Please use the 'Submit and continue' button at the bottom of each page to navigate through this form. Once the submit button is clicked you will not be able to return to your answers. Your answers are automatically submitted as you proceed through the form


1.1. Please select Yes to confirm you agree to the terms above

If you submit your answers you will not be able to return to this page.