Mabadiliko Intercultural Therapy Adult Online Referral Form 
The information on this form is only handled by registered data controllers or data protection officers for GDPR compliance. Please see the privacy policy at the end of this form for more details.
By completing this form you give consent, under data protection legislation, to process the information. 

After completing and submitting this form you will be contacted within 48 hours to arrange a consultation / initial assessment, please check your junk/spam mail in-case our reply lands there. 
Your consultation will be booked in for the earliest mutual available appointment which may differ from your ongoing therapy sessions. If you complete this form on the weekend, there might be a delay in response time. 

The consultation is an opportunity for us to assess together your therapeutic needs and suitability to the service. 

After the consultation you may be allocated to an associate therapist, therefore the person conducting your consultation might not be your ongoing therapist. Our current average time between consultation and therapist/counsellor allocation, varies depending on your preferences and availability, but is usually no more than 2 weeks.

We will do our best to match you with an appropriate therapist according to your preferences. However, we take many factors into consideration during the matching process to provide you with the most appropriate fit, therefore all of your preferences might not be fulfilled. 

Therapy fees range from £45-£70.
Therapy Terms and Conditions apply.
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Email *
PERSONAL DETAILS
First name *
Last name *
Phone number *
Date of Birth *
Home address and postcode
Please select what region is most appropriate to your location *
EMERGENCY CONTACT DETAILS
In case of an emergency during your session, please provide accurate contact details for someone we can contact on your behalf. 
First and last name of emergency contact *
Phone number and Email of emergency contact *
Is your emergency contact your Next of Kin *
GP INFORMATION
We collect this information for safeguarding and health and safety reasons
Name of GP *
GP surgery name and address *
GP phone number *
THERAPY EXPERIENCE
Please describe your reason for seeking therapy at this time
 *
Have you had therapy or counselling before? 
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If yes please include when, what type and for how long. 
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Was the therapy or counselling helpful? 
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AVAILABILITY AND PREFERENCES
We will match you to a therapist considering as much of your preferences as possible 
Please indicate your time preference
 *
Required
Please indicate your preference for in-person or online therapy
 *
Required
Please indicate the days you are most available for ongoing therapy
 *
Required
Please indicate any other preference for the therapist that might work with you *
Required
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