Application for Psychotherapy for those aged 18-25

Application for Psychotherapy for those aged 18-25

STRICTLY CONFIDENTIAL
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
Which pronouns do you prefer?*

He/Him/HisShe/Her/HersThey/Them/Theirs
Email*
Phone Number*
Date of Birth*

DayMonthYear
Approximate Household Income*
If you are able, please outline your reasons for seeking help
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

Rates are based on annual HOUSEHOLD income. Please pay for the first session as appropriate according to the scale below. These figures are for guidance. If necessary, the therapist will negotiate the fee for future sessions with you when you meet for the first time. *

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 18-25

Payment Methods