MindKind Therapies

Booking Form

Client Details

First name *

Last name *

Email *

Phone *

Date of Birth *

Gender *

Work Status *

GP Doctor Name *

GP Surgery Address & Postcode *

GP Surgery Telephone Number *

Are you currently taking any medication? *

Have you had counselling or therapy before? *

Please provide more detail of your current emotional status. *

I/We feel regulated but anxious and/or depressedI/We feel overwhelmed, with limited support and experiencing some intrusive thoughts.I/We currently feel in crisis. In addition to this booking consultation request, I confirm I have made contact with NHS 111, the Samaritans and/or have/will visit A&E for immediate emergency support if required.

Completion of this field is mandatory to ensure your wellbeing is closely monitored and protected. Please be advised my practice is not offered as an "in-crisis" service.

Please briefly describe your current situation and what sort of therapeutic support you may be seeking: *

Cancellation Policy

A cancellation fee applies if less than 48 hours' notice is given prior to your appointment. To cancel or reschedule, please contact MindKind Therapies by email at letstalk@mindkindtherapies.com.

Booking Details

Complete the form and click Pay Securely to confirm your appointment.