Therapy Interest Form
This form serves as a screening tool for both of us to ensure that I am the best therapeutic fit for you at this time. Thank you for taking the time to fill this out! Once you have submitted the form, I will aim to get back to you as soon as possible to discuss next steps.

- Viki

My Current Availability: Although I don't have immediate availability to take on new clients, I may have a slot opening up in late March or April 2024.

Data Protection: Your personal data will be stored and processed in accordance with the 2018 General Data Protection Regulation (GDPR). I take all reasonable steps to keep your personal details safe on digital platforms. I would only disclose information about your needs to others if I have serious concerns that you or another person were at immediate risk of harm. A full privacy policy is available here.

Emergencies: Please note that I am unable to provide emergency support, and if you are currently feeling in need of urgent help or experiencing a crisis, you should contact someone who can support you immediately, or call the NHS First Response Team on 111, to speak directly with a Mental Health Professional. Alternatively, you can call the Samaritans on 116 123.  Both services are open 24/7 and are free of charge.
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Email *
Personal Information
Full Name *
What would you like me to call you? (preferred name or nickname) *
Where are you based? Please share the city and country: *
Interest in Therapy
Where did you hear about me?
*
What would you like me to know about you and your decision to explore therapy at this time? *
What are you hoping to gain from therapy? *
What led you to reach out to me specifically? 

(Was there something that you saw or read on my website? Why is this important/relevant to you?)
*
Please check all boxes that apply to you presently OR in the past. If none apply, please select that box. 

(These are not immediately disqualifying, but will need to be further discussed to see if I am an appropriate fit for your needs at this time.)
*
Required
If you've selected something other than "none of the above" in the previous question, please share whether/how this is relevant to you currently.

(e.g., "I self-harm on a weekly basis" or "Addiction is something I want to focus on in therapy")
Practical Information
Online Therapy: I offer online sessions via Zoom video call. Please confirm that you have a private space to engage in online therapy. *
Fee: My fee is £80 per 50-minute session. I ask for payment via bank transfer in advance of each session. Does that work for you on an ongoing basis? *
Cancellation Policy: I ask for one week's notice to cancel or reschedule. Because the therapy I offer works best on a weekly basis, I reserve your weekly time slot for you and I'm able to allow each client up to two cancelled sessions in every 12-month period, which means I will not charge for those two sessions, as long as I have one week's notice. How does that sound to you? *
Availability: I usually reserve one particular weekly time slot for each client. Please share all your availability within Monday-Thursday 8am-3pm (UK time): *
As mentioned above, I don't have immediate availability to take on new therapy clients. Although I can't guarantee exactly when a slot will open up that matches your availability, I can let you know via email as and when it does.
*
Anything else you'd like to share? Any questions for me at this stage? You are welcome to ask later, too.

Thank you for taking the time to fill out this form. I look forward to getting in touch!
A copy of your responses will be emailed to the address you provided.
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