Contact

1. Client Information

Full Name

Date of Birth / Age

For under-18s: Parent/Guardian Name

Pronouns

Email

Phone Number

Address

2. Reason for Referral

Select Service
Individual TherapyCYP TherapyCouples/Dyadic TherapyThe ResetConsultationWorkshop

Briefly describe why you are seeking therapy

Have you had therapy before?

YesNo

If yes, please provide details (optional)

3. Therapist Preference (Optional)

Preferred therapist
No preferenceEshmitAnaFazilaNasimaEveSoirse

4. Practical Information

Preferred session format

OnlineIn-personFlexible

Availability for sessions (days/times)

Accessibility needs or considerations

5. Fees & Payment Acknowledgement

Therapy fees start at:

£80 per session for private clients

£95 per session for organisations / Local Authorities

Fees may vary depending on sliding scale, funding and service. Low cost rates are available.

6. Safeguarding & Risk

Any current safety concerns for self or others?

YesNo

If yes, please provide details (optional)

For under-18s: Any safeguarding information the therapist should know?

7. Consent

I confirm that I consent to EK Therapy using this information to assess suitability for therapy and to contact me regarding services. If completing this form for an under-18, I confirm I am the parent/guardian.