Therapy enquiry
I do not hold a waiting list, so completing this form will not place you on a waiting list.

If I contact to let you know there is no space available, I will delete your information from my files.

If a space is listed on my website as being available, please be aware that in the time that you complete this form, there is a possibility that any space is already taken. I will only offer initial consultations if a potential space is available so that I don't waste your time. However, the initial consultation is not the start of therapy, it is to decide if we are a good fit. It may be that I suggest a referral to another therapist or service following our meeting.

Please check the website  to find out about the sliding scale and see whether sessions that match the fee band you fall into are currently available: https://wildandwellbeing.com/faq-practical-info

Sign in to Google to save your progress. Learn more
Email *
Name *
Age *
Gender identity / pronouns *
Are you enquiring about: *
Required
If you are filling this form in on behalf of a child, are you:

(Please note, there is a legal requirement for therapists working with adopted children to be registered with Ofsted as an Adoption Support Agency (ASA) or work for a recognised ASA. I am not and so do not currently work with adopted children.  There's more info on the law for therapists and adopted children here)
Clear selection
Are you looking for sessions:
Are you looking for 
Clear selection
Briefly describe what you hope to gain from therapy
E.g., increased self confidence, feel more able to access calm, be able to set boundaries.  *
I operate a fee sliding scale. Please check the website  to find out about the sliding scale and see whether sessions which match the fee band you fall into are currently available: https://wildandwellbeing.com/practical-info
To ensure the financial sustainability of therapy, it useful to confirm that the current sessions I have available match the fee band you fall into. 
 *
I am not currently available to work with certain experiences and client groups: 

- I do not work with people who are already working with another counsellor or psychotherapist

- I am not currently working with perpetrators of sexual violence and/ or domestic violence. If you are a perpetrator of sexual violence and wish to change your thoughts/ behaviour around this, you may find this resource helpful

- If a member of your family is currently working with me, or has previously worked with me, I will not be able to work with you therapeutically

Additionally, I do not offer a crisis service and do not provide psychological support out of a pre-arranged session. If you feel that you require urgent support, are experiencing thoughts of suicide or feel that you are unable to keep yourself safe; please contact one of the following services:
​Your GP
The Samaritans - 116 123 (freephone)
Shout: Text 'SHOUT' to 85258
Call 999 or go to A&E if you feel unable to keep yourself safe.
 *
Please feel free to tell me about any access needs you would like me to know about at this stage  (if we start working together, there will also be another opportunity to share this later)

Please feel free to share anything about how you would like to be referred to (e.g. name, pronouns, title) that you would like to share at this stage (if we start working together, there will also be another opportunity to share this later)
I have very limited availability and will make clear what slots I have available currently before booking an initial consultation. Most slots will be during the daytime on weekdays and are most effective if there is a regular time and day each week. It can be useful to consider your availability for this. 

I do not keep a waiting list. If the day and times I can offer do not fit, you can choose to find another therapist or get back in touch with me at a later date to check my availability. 

If you have limited availability and will only consider sessions, certain days and times, please let me know your availability. 
9.30- 10.30am
10.30-11.30am
12.30-1.30pm
1.30-2.30pm
2.30-3.30pm
3.30-4.30pm
4.30-5.30pm
5.30-6.30pm
Monday (Lancaster)
Tuesday (Staveley indoor and outdoors)
Wednesday (online or outdoors)
Thursday (Staveley indoor and outdoors and online)
Submit
Clear form
Never submit passwords through Google Forms.
reCAPTCHA
PrivacyTerms
This content is neither created nor endorsed by Google. - Terms of Service - Privacy Policy

Does this form look suspicious? Report

Google Forms