Appointment

Please complete the details below and one of our team members will be in contact to organise your visit with us. Talk with you soon.

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Patient Details

First Name *

Surname *

Patient Date of Birth *

Phone *

Email Address *

Reason for attending

Instructions

So we can best match you with one of our clinicians, please tell us a little more about why you are wanting to see one of our clinicians. Please note that the more information we have available will ensure we are able to best fit you with one of our team. Information that will be helpful for us are some of the symptoms you have been experiencing, situations you may struggle with any outcomes you are looking for at the end of your sessions. If you would prefer to speak with one of our team directly regarding this, please indicate this below.

Existing or New Client *Existing ClientNew Client

Reason for visit *

Are you wanting to book for a formal assessment and report? *YesNo

For Children & Adolescents

Instructions

Please be advised that if you have shared custody with another parent or carer we will require consent from all parties for the child to engage in treatment. We will also require a copy of the court or parenting order for our file.

Parenting order in placeYesNo

Verification

Please enter any two digits *Example: 120 / 2

Type of Visit *

Loganholme Practice

Cleveland Practice