Oban CBT Clinic
Self-Referral Form
Health History Questionnaire
- please complete this form
to tell us about yourself
and provide details about
the problem you would like
support with.
DASS symptom measure
- please complete this form to
tell us about the type of
symptoms and the severity of
symptoms you experience.
Thank you for completing these questionnaires.
Results are sent to a secure e-mail account and are used solely for the purpose of self-referral.
Please see our Privacy Policy for details of how we protect your personal information.
If we do not feel confident that we can provide input to address your problems, we will signpost you to
alternative provision wherever possible.