Self Referral

If you are over 18 and looking for help, here at Ellern Mede we offer outpatient assessment and treatment services for private paying adult patients. Use this form to make an enquiry and we will be in touch to offer you guidance.

Self-Pay Enquiry Form

Your details

Where did you hear about Ellern Mede?*

How would you like us to contact you?*

What time would you prefer to be contacted?*

Select a condition*

Type of treatment programme*

Please indicate your your preferred payment option* I will be funding treatmentI have insuranceOther


I understand that by ticking this box and submitting this form, I consent to Ellern Mede contacting me by email or phone in order to process my enquiry. Ellern Mede will not pass your details onto other companies or third parties.

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Please call Susan Ramwell on +44 (0)20 3 209 7900 ext 227 to find out more. Or alternatively please feel free to email us at [email protected] or complete this enquiry form. Alternatively read about the NHS Referral process.

Your enquiry will be handled in the strictest of confidence and responded to the same or next working day. You are welcome to read our patient confidentiality policy.

After submitting this enquiry, you will receive an initial call or email to discuss service, price and payment options. We would need to receive some medical information such as a GP or Consultant letter. Should you wish to proceed you would have an initial assessment appointment.

Funding or payment arrangements will be discussed prior to your first appointment. We will send you our Terms and Conditions. Payment is in advance of each appointment.