Referral Request

Complete and send the form below and we will match you with a therapist based on the information you share and therapist availability.

Referral Request

On receipt of your completed form we'll match you with a therapist based on the information you share.

If you would like more guidance and support in finding the right therapist for you and for an opportunity to visit our space, please Book a Consultation.

First Name

Surname

Email address

Phone*

Preferred Mode of Contact

Any preference regarding the identities of your therapist (i.e. gender, sexual orientation)

Your broad availability (including preferred days/times for sessions)

How would you prefer to access your therapy

Any information about your particular therapeutic needs

Anything else you would like to add