Application for Psychotherapy

Application for Psychotherapy

STRICTLY CONFIDENTIAL
For those aged 26 and over
All the information you share with us is STRICTLY CONFIDENTIAL and stored securely. We use some of the information you provide to evaluate and improve our services. This information is never used in a way which would identify you as an individual.

To apply, please complete the form below and click the SUBMIT button. Once your application and the appropriate payment for the initial consultation has been received, we will be in touch with you by email to offer you an appointment
Full Name*

First NameLast Name
Age*
Date of Birth*

DayMonthYear
Which pronouns do you prefer*

He/HisShe/HerThey/Their
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
Phone Number*
Are you happy for us to contact you (please tick all that apply)*

by emailby phoneby post
Would you prefer your initial consultation to be*

in personvia video conferencingeither
Marital Status*

SingleMarriedPartnerDivorced/SeparatedWidowed
Nationality
Employment Status*

EmployedSelf-EmployedRetiredStudentNot in paid work
Occupation
Approximate Annual Household Income*
Are you in receipt of benefits*

YesNo
On a scale of 1-10 (where 1 is poor and 10 is excellent) how do you rate your current wellbeing? *

1

2

3

4

5

6

7

8

9

10

1 is Poor, 10 is Excellent
Please would you outline the difficulties which have led to you seeking help.
How do you feel we may be able to help you?
Could you tell us something about your present relationships?
Is there anything else about your situation that you think we should know?
Sometimes we find it helpful to contact your GP. Would you be prepared to give us permission to do this?

YesNo
If YES, please provide your doctor's name, address and telephone number.
Are you currently taking any prescribed medicines?*

YesNo
If YES, what are you taking?*
Have you consulted anyone about your difficulties, either recently or in the past?*

YesNo
If YES, could you please give details*
How did you hear about St Marylebone HCC?
Could you tell us how you found filling in this questionnaire?

For Initial Consultation - up to 1.5 hours. Rates are based on annual HOUSEHOLD income:*

If there is any problem with payment or you are only able to pay in cash, please telephone us to discuss a way forward on 020 7935 5066.

We hope that no one is prevented from attending through lack of money.

Some assistance may be available from our bursary fund.
Should be Empty:

Application for Psychotherapy

For those aged 26 and over

Payment Methods