IPS Website Contact Form

Website Contact Form

Contact Form
Full Name*

First NameSurname
Address

Street Address

Street Address Line 2

CityRegion

Postal Code
Date of Birth*

DayMonthYear
Date
Phone Number*

Country CodePhone Number
E-mail*
example@example.com

GP Name and Practice *

GP NamePractice Name
Emergency Contact Name*

First NameLast Name
Emergency Contact Phone Number*

Country CodePhone Number
Can you tell us a bit about why you are seeking therapy at this time?*
How did you hear about us?*

Social MediaOnline SearchRecommendationOther

Next Steps...
We send you a calendar link to arrange a 20-minute phone call to help us understand what brings you to therapy, ascertain which of our therapists feels the best match for you or signpost you to a more appropriate service.

We ask that you commit to eight sessions with one of our therapists; after that, we will ask if you wish to continue with us.

Our sliding scale is between £20-100 and we ask that you pay what you can towards your therapy. We also ask that you contribute £20 towards the cost of the time it takes us to get you to your therapist and conduct a review for you after the eight weeks are up.

Please submit your form if you wish to proceed with your application for Integration Psychotherapy.
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