Make a Referral

Are you a patient?

This form is primarily for referring surgeons and practitioners. If your surgeon has asked you to contact us directly, you are very welcome to use this form or call us on +44 (0)20 3488 3655. Please mention who referred you.

Your details

Referring clinician *

Specialty *

Practice / clinic *

Location

Email *

Phone *

Patient details

Patient initials *

Date of birth (approx.)

Sex

Procedure planned *

Assessment details

Assessment type *

Urgency *

Preferred appointment mode

Clinical information

Clinical concerns and reason for referral *

BDDQ result (if administered)

PHQ-9 score (if available)

Psychiatric history disclosed by patient

Anything else we should know

Consent confirmation: By submitting this form I confirm that the patient has consented to their details being shared with Cosmetic Surgery Psychiatry (part of Harley Street Mental Health) for the purpose of arranging a psychiatric assessment, in accordance with UK GDPR and the Data Protection Act 2018.

All information is handled confidentially. Patient identifiable data is processed in accordance with UK GDPR. Cosmetic Surgery Psychiatry is a trading name of Harley Street Mental Health Ltd.

What happens after you submit

We will acknowledge your referral and be in touch within one working day.

Acknowledgement — 1 working dayWe confirm receipt, confirm the assessment type, and provide a fee quote if required.

Appointment scheduledWe contact the patient to arrange their appointment — in person or by video. Routine: 1–2 weeks. Urgent: 48–72 hours.

Patient attends assessment60–90 minute consultation with our Consultant Psychiatrist. Validated screening tools administered.

Written report to youReport sent within 5–7 working days (3 days on rapid pathway). Clear recommendation included.

Part of HSMH

Harley Street Mental Health

Cosmetic Surgery Psychiatry is delivered through the Harley Street Mental Health group — one of the UK’s leading private psychiatric practices, based at 10 Harley Street, London.

HSMH offers a full range of specialist psychiatric services, including psychotherapy, neuropsychology, ADHD assessment, and mood disorders — meaning that patients referred via Cosmetic Surgery Psychiatry who require ongoing treatment can be supported within the same clinical group.

www.hsmh.co.uk → Visit full website