Enquiry Form Name * First Name Last Name Email * Phone * (###) ### #### What is your availability for sessions? Monday daytime Monday evening Tuesday daytime Tuesday evening Wednesday daytime Wednesday evening Thursday daytime Thursday evening Friday daytime Friday evening How will you be funding therapy? * Self-funding / pay myself Insurance - AXA Insurance - BUPA Insurance - WPA Insurance - Cigna Insurance - Aviva Insurance - Healix Other - please state Other Reason for enquiry * Please answer the following questions about yourself. (If you are a parent or carer completing this form on behalf of a child or young person, please answer to the best of your knowledge about them). * In the last 6 months, have you/they had any thoughts about hurting yourself/themself, or ending your/their life? Yes No If yes, are these thoughts something you (/they) feel at risk of acting on? Yes No * Have you/they ever, at any point in your life, tried to harm yourself/themself or end your/their life? Yes No If you answered ‘Yes’ to any of the above and would like to share anything else (optional), please use the space below: Thank you!
