Thank you for contacting to us. Please allow us 1 to 2 business days to respond to your inquiry. If you need to contact our referrals therapist immediately to make an appointment, call us directly at 0207 247 9063. This form is transmitted via our secure server and your information will not be used for any purpose other than this consultation. Your name: Your email address: Your mobile number: Are you applying for our reduced fee schemes? (you are earning less than £20,000 per annum gross) YES NO Your date of birth: 1. 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. January February March April May June July August September October November December 1940 1941 1942 1943 1944 1945 1946 1947 1948 1949 1950 1951 1952 1953 1954 1955 1956 1957 1958 1959 1960 1961 1962 1963 1964 1965 1966 1967 1968 1969 1970 1971 1972 1973 1974 1975 1976 1977 1978 1979 1980 1981 1982 1983 1984 1985 1986 1987 1988 1989 1990 If you want to book in for an initial consultation, please indicate days and times that are usually possible for you to make. If you are applying at standard fee rates, you might also let us have a note of your annual gross income, so that we can let you have a note of the cost of the initial consultation. Without your income declaration, the initial consultation standard fee will be £35.00. My available days are: My available times are: My Annual gross income is: Would you like a therapist to call you? YES NO Would you like a therapist to email you? YES NO If you have any another enquiry that you would like us to reply to, or you want to specify any preferences/ difficulties that we need to consider or talk to you about when making your appointment, please enter them here.

10 Cobb Street, London E1 7LB  19 Wentworth Street  London E1 7TB telephone number given on email request