Self Referral Form

Taking the first step toward therapy can feel like a big decision, and I want to make sure you feel comfortable and supported. By filling out this form, you’re helping me understand your needs so I can assess how best to support you.

Once I’ve reviewed your information, I’ll send you a link to book a free initial session

at a time that works for you.

This session is an opportunity for us to explore whether we're a good fit based on my experience and your goals for therapy. It’s a space where you can share what you’re looking to achieve and ask any questions you may have before deciding if you’d like to proceed.

If you are still not sure and have a couple of questions before filling in the form

Would it help to have a 15 minute chat to put your mind at ease?

YES PLEASE

Preferred Pronouns

First Name*

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Surname*

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Date of Birth*

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Gender

Ethnicity

Sexuality

Any Disabilities

Telephone*

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Email*

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Address*

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GP Surgery Name*

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Emergency Contact Name*

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Emergency Contact Number*

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Any Medications*

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Any Previous or Current Mental Health Diagnosis*

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Have you ever or are you currently struggling with a dependency with alcohol or drugs - YES or NO*

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Have you ever or are you currently struggling with any other form of dependency or addiction - YES or NO*

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Have you ever experienced any childhood trauma - YES or NO*

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Have you ever been a victim or witness of domestic violence - YES or NO*

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Anything else you would like to share

I hereby agree that this data will be stored and processed for the purpose of establishing contact. I am aware that I can revoke my consent at any time.*

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* Indicates required fields

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Thank you! We will get back to you as soon as possible.

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