Paid Counselling Enquiry

Name*

Title e.g. Mr/MissFirst NameLast Name

Email*

example@example.com

Phone Number*

Area CodePhone Number

Where do you live

Town/City e.g. HatfieldCounty e.g. Hertfordshire

Which of the following best describes your therapy needs*

Anxiety disorders such as phobias, obsessive-compulsive disorder, and social anxietyDepressionStressPost-Traumatic Stress Disorder (PTSD)Mental and emotional distress from long term health issuesChallenging life events such as bereavement, job loss, divorce etcNot sure

Request an appointment at a time that suits you*

	Morning (8am-12pm)	Afternoon (1pm-5pm	Evening (5pm-8pm)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Select the days and times of the current/upcoming week which are most convenient for you. Once your enquiry has been recieved, our team will call you to discuss your situation in more detail, and agree and confirm the exact appointment time with you.

Any further details you would like to provide, or questions you would like to ask?