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.

After completing and submitting this form you will be contacted within 72 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. (Please note, we will prioritise your preferences according to your psychological needs, so if one of your preferences is for face-to-face therapy, but we feel the most suitable therapist for you is only available online, we will offer you online therapy. We will always match you according to your ethnicity and gender preferences, but sometimes there might be a waiting list, so we will consult with you before compromising your preference request).

Therapy fees range from £45-£70.
Therapy Terms and Conditions apply.

COVID-19
The Mabadiliko Intercultural Therapy Centre is based in Forest Hill, Southeast London and opened for face-to-face therapy sessions from January 2022. We do not insist that persons attending the centre are vaccinated (including staff), but you will be required to follow hygiene and Covid-19 health and safety procedures.  
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Email *
First name *
Last name *
Your email *
Your main contact number *
Your home address and postcode
Please select what region is most appropriate to your location
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Age range *
Date of Birth *
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DD
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YYYY
First and last name of an emergency contact *
Phone number for emergency contact *
Email for emergency contact *
Is your emergency contact your Next of Kin? *
GP name *
Name and address of GP practice *
Phone number of GP practice *
Have you had therapy or counselling before? If yes please include when, what type and for how long. (If you had private therapy please state Private - you DO NOT need to state the therapists name) *
Was the therapy or counselling helpful? *
Please describe your reason for seeking therapy at this time *
Please indicate the days you are most available for ongoing therapy *
Required
Please indicate your time preference *
Required
Please indicate your mode of therapy preference *
Required
Please indicate any other preference for the therapist that might work with you *
Required
How do you identify your gender or sex *
Do you identify as the same gender from birth *
Are you pregnant *
Do you have any children? If so how many and how old are they. (Please mark N/A if you do not have any children) *
Are you an unpaid carer / do you support a family member or friend with care needs? *
Are you employed or unemployed? If employed what is your occupation? *
Are you a student? *
Are you a counselling student? *
How would you describe your ethnic/cultural background? *
How would you describe your religious or spiritual beliefs, including influences from upbringing? *
Do you have a disability or learning difficulty (if yes please give details below) *
Do you have any mental health diagnosis or undiagnosed concerns? If yes please give details below *
Please provide the name and dosage of any medications you have been prescribed for your mental health (past or present). *
When did you start and/or stop taking this medication (please state N/A if you are not taking or have never been prescribed any medication for your mental health) *
Do you have any physical health concerns *
Are you taking medication for any physical health concerns *
Do you consider yourself to have a substance misuse problem? *
How did you find out about Mabadiliko Therapy *
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