bookings

Getting started

First Name*

Last Name*

Email Address*

Mobile No

Date of Birth*

What brings you to therapy?* What brings you to therapy?* Anxiety / worry Depressed mood Relationship problems Family issues Emotional regulation problems Stress / burnout Life transition Grief / loss Trauma/PTSD Adverse childhood experiences Identity or gender Parenting concerns Self-esteem / low self-worth Identity Neurodiversity: ADHD, autism Disordered eating (binge, restriction) Communication and assertion Sleeplessness Other

What are you hoping to get out of your sessions?

What approach do you think might feel most helpful for you? What approach do you think might feel most helpful for you? Practical tools and strategies I can use day-to-day Space to talk and reflect more deeply Direct, honest input from my therapist Understanding how patterns, relationships, or past experiences impact me A structured, goal-focused approach I’m not sure / open to guidance

Please share some detail about your specific presenting concerns so that we can book you with the best practitioner possible:

Risk, safety, and psychiatric diagnoses

Are you experiencing current thoughts of self-harm, suicide, or harm to others?* Are you experiencing current thoughts of self-harm, suicide, or harm to others?* Yes No Prefer not to say

In the past 6 months, have you experienced self-harm, suicidal ideation, or suicide attempt, that resulted in engagement with a psychiatric treatment service? (e.g. emergency department, inpatient psychiatric unit, CATT, CYMHS, HOPE etc)* In the past 6 months, have you experienced self-harm, suicidal ideation, or suicide attempt, that resulted in engagement with a psychiatric treatment service? (e.g. emergency department, inpatient psychiatric unit, CATT, CYMHS, HOPE etc)* Yes No

If you answered yes to either question above, please provide further information (e.g. detail the nature of your concerns and if relevant, the mental health service you have been/are involved with):

Have you previously received any of the following diagnoses?* Have you previously received any of the following diagnoses?* Schizophrenia/psychosis Bipolar disorder Borderline personality disorder Intellectual disability Autism spectrum disorder None of these diagnoses apply to me

If you have been diagnosed with one of the above, please include any further information you think

Do you ever hear or see things that other people do not, feel paranoid, receive messages through the tv/radio, or hold strong beliefs that most others do not?* Do you ever hear or see things that other people do not, feel paranoid, receive messages through the tv/radio, or hold strong beliefs that most others do not?* Yes No

Do you experience any problems with alcohol or substances?* Do you experience any problems with alcohol or substances?* Yes No Prefer not to say

Availability and practitioner preference

If you have a preferred practitioner, please include their name here:

Please include your availability preference (e.g. weekday/s, time of day). Please be as specific as possible. *