Book an Appointment

Client Intake

First Name

Last Name

Name of Partner (first name only) if seeking couple's therapy

Name of Child if seeking children's/adolescent/young person therapy

Home Address

Date of Birth

Age

Email of Partner if seeking couple's therapy

Telephone

Telephone of Partner if seeking couple's therapy

Confirm Consent of the method to be contacted by

Telephone

Preferred Times for an appointment

Morning (8 am – 12 noon)

Afternoon (12 noon – 5 pm)

Evening (5 pm to 10 pm)

Any time

Type of therapy required

Adult

Couple's

Child/Adolescent/Young Person

Family

Low Cost Counselling (Our low-cost counselling service is facilitated by professional trainee therapists working towards the completion of their therapy training.)

Quit Smoking

Therapist gender preference

Reason for Seeking Therapy

Do you have any physical disabilities? If yes, please provide details.

How did you hear about us?

I hereby consent to the storage of my submitted information by this website, allowing White Lodge Therapy to respond to my enquiry. This form collects sensitive personal information to facilitate communication with the Practice Partners and assist in scheduling a therapy appointment. For details on how your submitted data is protected and managed, please refer to our Privacy Policy. Please check our Privacy Policy to see how we protect and manage your submitted data.

Do you need help with adoption or fertility issues in therapy?

Signature

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Thank you for taking the time to complete the Client Enquiry Booking Form. We wanted to let you know what happens next.

A Practice Partner will reach out to you promptly to confirm an available appointment with a therapist. In the meantime, please feel free to contact our office on 01376 440920 where you will speak with our Practice Secretary, Courtney, or one of her team.

Your initial session with your therapist will be an assessment meeting where you will explore the possibility of working together. If mutually decided, your therapist will begin therapy under an open-ended contract, aiming to continue sessions until you both agree the work is finished. The initial assessment will involve discussing your history and outlining the treatment plan, including the duration and frequency of future sessions, all to be mutually decided.

We will be in touch again shortly.

White Lodge Therapy

Client Enquiry Booking Form (*required fields)

Our Therapists are Members of a Professional Body

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