Parkinson’s Care and Support UK
Acceptance and Commitment Therapy (ACT) Self-Referral Form

This self-referral form is a way to access Parkinson’s Care and Support UK’s ACT. ACT is particularly suitable for people who are either newly diagnosed with Parkinson’s or who have YOPD (Young Onset Parkinson’s Disease).The service encourages people to embrace their thoughts and feelings rather than fighting or feeling guilty for them. ACT is based on the idea that trying to rid ourselves of pain and distress increases it and turns it into something traumatic. The alternative is to accept it- but that does not mean giving up, being defeated or agreeing with suffering. Acceptance is an acknowledgement of and a willingness to allow these experiences

Personal details


GP Information

Are there any issues with alcohol or recreation drugs?

Data Protection and Consent

By applying for the Parkinson’s Care and Support UK ACT Service, I consent to:

  • My personal data being shared between my GP, Parkinson’s Care and Support UK and our therapists if required
  • Confidential information received sent from Parkinson’s Care and Support UK to their therapist,to be usedfor all purposes relating to the assessing my application and the carrying out of ACT.

Please note that the Parkinson’s Care and Support UK ACT service is not an emergency service. In the case of an emergency, we request that the patient contacts their GP or visit their local A&E department.