If you would like to self-refer to either our Private or Low Cost Therapies, please complete the form below.  Please visit our FAQ page for questions and answers regarding availability and other information.

Disclaimer:

Please note we are unable to complete reports or provide any information for benefit appeals or re-assessments.  This includes ESA and PIP payments.  Full information about this can be found on our FAQ page.

Please note all fields are required to complete your registration.

Private & Low Cost Referral form

Which of our therapies are you making a referral for? *
Please tick all relevant boxes
If you have chosen Couples Counselling, please fill in your partner's full name and contact information here. Please note we cannot process your registration without your partner's contact information and agreement to treatment.
Name *
Name
Address *
Address
Can telephone messages be left? *
Will you accept text messages and automatic appointment reminders
Can we contact you either in writing or via telephone for feedback about the service you have received from us; during or after completion of treatment? *
This is for internal purposes. Any feedback will be kept anonymous.
We will not write to your GP or make contact with the surgery without your consent.
Do you have a disability?
This is for determining accessibility to our locations.
This is for determining accessibility to our locations
Please select which treatment location you would prefer to attend. *
Please tick all that apply. Please note: choosing more than one location helps us in allocating you to a therapist within a quicker time frame. Whilst we will endeavour to meet your preferences, due to the high demand for this service, it may not always be possible. Please visit our FAQ page for further information.
What time of day would be best for your appointment? *
Tick all that apply. Whilst we will endeavour to meet your preferences, due to the high demand for this service, it may not always be possible. Please visit our FAQ page for further information.
What days of the week would be best for your appointment? *
Whilst we will endeavour to meet your preferences, due to the high demand for this service, it may not always be possible. Please visit our FAQ page for further information.
Employment Status
Please let us know your gross income per annum.