Blue River Psychology Initial Therapy Enquiry Form

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Please complete the form below so that we can understand your needs and think about how we could provide you a service.
Most people who use this online form tell us that it takes between 5-10 minutes to complete.
By filling in this form you will be helping us to deal with your enquiry as swiftly and as efficiently as possible.
Once you have completed this form, Dr Lamba will arrange a time with you for an informal telephone consultation to discuss the options available (Please note we are a busy practice and may have waiting lists from time to time). Please complete the form fully otherwise we will be unable to process your enquiry.

Email *

Full Name *

Mobile Number *

Date of Birth *

YYYY

How do you identify your gender? *

Please state your address (including postcode and country of residence) *

Nationality *

How do you identify your ethnicity? *

Religion *

Marital or Relationship Status *

Child Status (number of children and ages) *

GP Details (We won't be able to pursue your enquiry without this information) *

Are you pregnant? And if you are, please provide details of how many weeks/months and the estimated date of delivery *

Please can you provide details of an emergency contact, this can be a person who is a family member, a next of kin or close friend (we only need this in the event of an emergency). Please provide their FULL NAME, PHONE NUMBER and what your RELATIONSHIP is to them. *

Referral Type - Is this a *

Self-Referral

Referral from a Psychologist/Therapist/Psychiatrist

Third Party Organisation

Are you considering face to face or online appointments? (Please note currently and for the foreseeable future we are online only) *

Are you considering individual psychology or couples work? *

Individual

Couples Work

Required

What days are you available for therapy appointments? Please state preferred days and whether morning or evening works. *

Please can you describe what difficulties you are experiencing, how long you've been feeling this way and your overall reasons for seeking psychological therapy? *

Please provide details of any current and/or historical diagnosis of mental health conditions (through the NHS, any other organisation, and/or healthcare professional). *

Have any other services been involved in supporting you currently, recently or any point in the past? If yes, please state which services. *

Are you currently, or have you ever been at risk of harming yourself and/or others at any point? *

Please provide details of any underlying physical health conditions *

Are you on any medication? *

How will you be funding therapy appointments? *

Self-Funding

Health Insurance

Other:

State the name of the Health Insurance provider if funding through them *

Therapy fees start from a £110 and upwards per hour (usually a 50 minute appointment) depending on if you are self-funding or if a third party organisation is funding your sessions. You may be able to meet with a therapist weekly or fortnightly (setting the appropriate frequency of therapy meetings needs to be carefully assessed and agreed). *

This makes sense and I understand the investment required for therapeutic work.

Unfortunately I won't be able to pursue things further (You understand we may not be able to proceed with your enquiry and suggest you contact other therapists).

If deemed appropriate, you may end up seeing an Associate Psychologist/Therapist who works as an independent practitioner with us (particularly if Dr Lamba's therapy caseload is full). This initial client enquiry form will need to be shared with the Associate in order for them to consider providing you therapy support. Please can you state you agree to your information being shared with Associates (please select options below) *

Understood and Agreed

No I do not want to share my information with an Associate (You understand we may not be able to provide a service in this case)

Which Associate Psychologist/Therapist are you interested in meeting for a consultation and potential therapy sessions? (Please read their profiles on our website if you are unsure who you might wish to meet. If you are still unsure then please select that option for now). *

Dr Selina Tour - Clinical Psychologist

Dr Prarthana Shetty - Counselling Psychologist

Bhavna Sennik - CBT Therapist

Unsure

If your referral is not processed for any reason, we will destroy this intake form. This is because there will be no need for this information to be stored or held by us in that situation and we would not be providing a service of any kind, so there is no purpose for your personal information to be held. Do you understand and agree? *

Understood and Agreed

I agree that I will seek GP or Emergency Services support, if I feel I am in crisis. *

Yes, I agree.

No, I do not agree to this (you understand that if you select this option your referral cannot be processed and we'll be unable to take your therapy enquiry further).

Please confirm you agree with this statement: I have answered the above questions truthfully and honestly, and to the best of my knowledge. I recognise that withholding important information that is necessary for reviewing and/or processing my referral, to provide a potential therapeutic service can be harmful and prohibits therapists from providing quality service of any level. *

Confirmed and Agreed.

I do not agree to this statement (you understand we cannot pursue your referral/enquiry further)

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