Intake Form

Get introduced to a qualified therapist

Complete this form to help us match you with a therapist experienced in digital-age challenges. Please note: we do not provide diagnoses or emergency support. If you're in immediate danger, call 999. For 24/7 support call Samaritans 116 123 or text SHOUT to 85258.

What are you mainly looking for help with?

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If something else, please describeDesired OutcomeIf something else, please describeSession PreferenceLocation (town/postcode)Budget Per SessionAvailability

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Therapist Gender Preference

Faith-Sensitive Practitioner

Languages

Neurodiversity-Informed Practice

Additional InformationFirst NameLast NameEmail AddressMobile

I understand this is an introduction service, not medical care or crisis support *

I agree to be contacted by email to arrange an introduction *

I've read the Privacy Notice *

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