Referrals

Self-refer online

You can self-refer online using the form below. A waiting list will be in operation, please email Andrew if you want to know how long this is before starting.

When it is time to begin you will be sent over a contract to sign and you are ready to go. Once you have had your application accepted you can book your session via email (you must have your referral accepted first or your booking is automatically cancelled) and once you have a confirmed booking you can pay by direct bank transfer. Pricing is £45 per session, with low income concessional prices available.

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Thank you for getting in touch!

Name

Address (Including Postcode)

Gender

Date of Birth

Phone Number

Occupation

Additional Support Needs

Emergency Contact Name

Emergency Contact Address (Including Postcode)

Emergency Contact Phone

Emergency Contact Email

GP Name & Surgery

GP Phone

GP Address (Including Postcode)

How did you hear about us?

Declaration – I accept my therapist may contact these people in an emergency

Reason for Referral

(Please summarise Reason for Referral in fewer than 30 characters, i.e. ‘Anxiety’, ‘OCD’, ‘Low Mood’).