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New enquiry form
Please complete this form for the person who will be receiving therapy.
Please note by completing this form, you are agreeing to us holding your data in order to fulfil your request.
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* Indicates required question
Email
*
Your email
Full name
*
Your answer
Mobile phone number
*
Your answer
Age of person seeking therapy
*
Your answer
Name of person seeking therapy
*
Your answer
What are the reasons or concerns that you are seeking help for?
*
Your answer
Have you been referred to us by another professional? If so, please state their name and profession here.
Your answer
Are you planning to use an insurance plan to fund your treatment? If so, please state the name of your provider here. (Please note if you are self-funding your appointments, there may be more availability to offer you).
*
Your answer
Please indicate when you can attend appointments. (Please note that the more flexibility you can offer on availability (daytime/evening) the quicker you are likely to be seen)
*
Your answer
Do you have a preference for online or face to face appointments? (Please be aware that if you can be flexible there may be more availability to offer you)
*
Online only
Face to face only
No preference
If you have a preference for face to face appointments there may be different locations available. Please indicate if you have a preference for a specific location.
Banstead
Open to other Surrey locations such as Haslemere, Guildford, Merstham
No preference
Clear selection
Do you have a specific type(s) of therapy/therapist in mind? (Please see indication of cost per session)
*
Clinical Psychology (£125 per session)
Cognitive Behaviour Therapy (CBT) (£125 per session)
Eye Movement Desensitisation Reprocessing (EMDR) (£125-150 per session)
Couples Therapy (£150-£200 per session)
Counselling/Psychotherapy (£50-£110 per session)
Play Therapy (£85 per session)
Family/Parent Work (£85 - £120 per session)
ADHD/ASD Assessments (further information will be provided on request)
Don't know
Other (please describe under "add any information" item below)
Required
Do you have a preference for seeing a male or female therapist?
*
Female
Male
No preference
Please add any other information you would like us to know?
Your answer
Thank you for completing this form. Someone will be in touch by email initially regarding your enquiry. Please note that there may be a wait to hear back from us during holiday
periods but we will be in touch as soon as we can.
Your answer
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