Contact Form for IFS Support

JavaScript isn't enabled in your browser, so this file can't be opened. Enable and reload.

Welcome, and well done for getting this far to request some psychological support. IFS Support Sessions are available to book as single-sessions and are based in Internal Family Systems. This kind of support may help you to alleviate difficult thoughts and emotional distress, by facilitating inner connection to your personal needs, resources and strengths. By the end of a session, you may feel more confident and at ease.

To get in touch to arrange a session, please complete the self-referral contact form below with all your details, and I'll respond soon.

All the information that you send me will be held according to my privacy policy: https://www.kesleycage.com/privacy

Kesley Cage

Email *

Name *

Date of birth *

Address *

Phone number *

Emergency contact *

(friend or relative)

Wellbeing Information

Your responses to this part of the form may be helpful to assist with your support session.

Name and address of GP

Brief description of medical conditions

Prescribed medication

Substance usage

(e.g. drugs, alcohol)

Wellbeing Assessment

During the last 2 weeks...

Not at all

Rarely

Sometimes

Often

I have slept well

I have consumed a nutritionally balanced diet

I have physically exercised

I have enjoyed socialising

I have been feeling positive

I have been thinking clearly

Clear selection

What is the issue that you would like support with?

Please give brief details (one or two sentences).

Have you been impacted by any past adverse experience or significant event that still troubles you? *

No, I'm feeling ok about the past, my issue is more in the present

Yes, but this isn't troubling me at the moment, my issue is not related

Yes, I am coping fairly well after what happened, though I need a little help now

Yes, I normally cope well, however I suddenly feel very upset connected with what happened

Yes, I have experienced trauma, and I haven't been coping well for a long time

What brings you happiness?

Why have you chosen to seek support now?

(One or two sentances.)

What I would find most helpful from a session is... *

Emotional balance

Feeling 'centred' and 'grounded'

Emotional release

Inner calm

To feel seen, heard and 'witnessed'

Compassionate connection

Understanding my mind

Breathing space and time out for self care

Techniques to take away and practice

Other:

Appointment preferences *

Appointments will be offered asap within current availability. Waiting times are usually a few days or less. Asterisks (*) indicate a £30 premium surcharge.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday*

Sunday*

Morning

Afternoon

Evening*

Appointment length: *

If you are experiencing a high level of stress, then please choose a 90 minute appointment. If you feel you need less support, then please choose a 60 or 30 minute session.

90 minutes (£110)

60 minutes (£80)

30 minutes (£40)

A copy of your responses will be emailed to the address you provided.

Submit

Clear form

Never submit passwords through Google Forms.

reCAPTCHA

Privacy Terms

This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy

Forms