Brown Therapist Network Client Therapy Enquiry
If you would like to see one of our associate therapists for therapy, please complete this form.
Visit https://browntherapistnetwork.com/our-therapist-team/ to see who we have within our team that can help you, before completing.
This screening form will take approximately 7 minutes to complete.
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Email *
Full Name *
Email Address *
Telephone/Mobile Number *
Date of Birth *
MM
/
DD
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YYYY
How do you identify your gender? *
Full Postal Address *
GP Details *
What are you struggling with? *
How long have you been feeling this way? *
What have you tried previously? (therapy and/or medication) *
When would you be available for therapy sessions? *
Required
How do you prefer to have therapy sessions? *
Do you have a preference for a particular therapist within our team? View their bio's here: https://browntherapistnetwork.com/our-therapist-team/ *
Required
How will you be paying for therapy sessions? *
If you will be using health insurance to fund the therapy please let us know the insurance company.
I agree that I will seek GP or emergency care if I feel I am in crisis. *
Required
I have read and agree to the terms and conditions and consent to my data being shared with associate clinicians. https://drive.google.com/file/d/1haH7n4TXzpZe8TVwBGqx6aAS3uvGxobl/view?usp=sharing *
Required
Would you like to keep up to date with special events, workshops and all the great things that we do at the Brown Therapist Network? If you tick yes we will add you to our mailing list and you can opt out any time by emailing us at hello@browntherapistnetwork.com *
A copy of your responses will be emailed to the address you provided.
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