Individual therapy Appointment Request "*" indicates required fields Your Name* First Name Last Name Your Age*Please select18-2021-2526-3031-3546-5556-6566+Preferred Pronouns*Please selectShe/HerHe/HimThey/ThemShe/TheyHe/TheyPhone Number*Email Address* Who is your GP?*Your postcode*Who referred you?Have you had therapy before?* Yes No Any History You Feel is Relevant?Areas of concern: please say a little bit about what you would like help with*Please list all possible days / times of day you could be available for ongoing appointments*Do you have a Mental Health Care Plan (MCHP)?* Yes No In the process of obtaining one Please note WE DO NOT BULK BILL but we accept MHCPs.We are unable to undertake medico-legal assessments, or to prepare submissions for people undertaking court proceedings. Are you currently engaged in, or do you expect to be engaged in, any legal proceedings?* Yes No Is there any other important information you feel we should know or bear in mind?If you have filled this in on behalf of the client, please clearly state your name, relationship to the client, whose contact details you have included above, and confirm that you have consent to add the client to our waiting list Please check your spam or junk mail folder if you do not receive an email.
