Enquiry Form

Enquiry Form
Thank you for getting in touch.

Whether you're looking for support for yourself, your child or your family, completing this form is the first step. The information you provide will help me understand your situation and determine the most appropriate way forward.

I aim to respond to all enquiries within 2 working days.
Section 1: What are you looking for support with?
Please tick one
Section 2: Your Details
Name

First NameLast Name
Contact Number
Email Address
Preferred contact method
- Please tell me a little about what's been happening and what has led you to seek support at this time.
- What are you hoping will be different through therapy?
- What days and times are generally suitable?
- Preferred time
- Preferred frequency
- Anything else you'd like me to know?
- Parent/carer's name
  
  First NameLast Name
- Child's name
  
  First NameLast Name
- Child's date of birth
  
  MonthDayYear
  Date
- Child's school
- Who has parental responsibility?
- Is there a court order in place?
- Who lives at home with your child?
- Please tell me about your main concerns and what has led you to seek support at this time.
- Has your child previously received counselling or therapy?
- If yes, please provide brief details.
- Does your child have any diagnosed or suspected additional needs?
  
  Other
- Is your child currently receiving support from CAMHS or any other professional?
- If yes, please provide brief details.
- Are there any immediate concerns about your child's safety or wellbeing that I should be aware of?
- Who would be available to attend appointments if recommended? (Please tick all that apply.)
  
  Other
- If 'other' please specify
- What days and times are generally suitable?
- Preferred time
- Preferred frequency
- Anything else you'd like me to know?
- Who will be attending?
- Child/children's ages
- Please tell me a little about what's been happening and what support you're looking for.
- What are you hoping will be different following our work together?
- What days and times are generally suitable?
- Preferred time
- Anything else you'd like me to know?
- Who is the support for?
- Who would be available to attend appointments if recommended? (Please tick all that apply.)
  
  Other
- If 'other' please specify
- Please briefly tell me about the difficulties your family is experiencing.
- What are you hoping will change?
- What days and times are generally suitable?
- Preferred time
- Preferred frequency
- Anything else you'd like me to know?
- Organisation
- Role
- How can I help?
- Organisation (if applicable)
- Which workshop or training are you interested in?
- Tell me a little about what's been happening and what you're hoping support might help with.
- Other
- Please provide details for 'recommendation' or 'other':
- Before You Submit
- Thank you for taking the time to complete this form.
  
  I'll review the information you've provided and aim to respond within 2 working days.
  
  If I feel another service would be more appropriate for your needs, I'll always discuss this with you before arranging an appointment.
Should be Empty:

Enquiry Form

Section 1: What are you looking for support with?

Section 2: Your Details

Before You Submit