Self-Referral
Welcome, and well done for getting this far. Please add your contact details and as much optional extra information as you feel comfortable to share. 

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

You'll hear back from me within a few hours or days after you've filled out the form. 

If you wish to e-mail me directly, please contact: kesleycage@pm.me
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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 therapy, however if you're someone who doesn't like filling in forms, then that's no problem, this section is optional and you can leave it blank and scroll down to click 'submit'. I may request this extra information from you when we talk, however it's useful to share it beforehand if you can.
What are the current personal issues that you would like to talk about in therapy?
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/who supports you in your life at the moment?
Why have you chosen to seek help at this particular point in your life? *
What outcomes would you like from therapy?
What I would find most helpful from therapy is...
Clear selection
Therapy session-length:
Clear selection
Appointment preferences
Asterisk (*) indicates £30 premium surcharge.
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday*
Sunday*
Morning
Afternoon
Evening*
A copy of your responses will be emailed to the address you provided.
Submit
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