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Your details
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Male
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Other details
The following details are optional and should only be completed if they're relevant to your issue

Straight

Gay / Lesbian

Bi-Sexual
Other
What do you need help with?
What's worrying you?
Please describe the main issue you are seeking help for, along with any background details you feel are relevant.
The details you enter on this document may be seen, in an anonymised form, by the practitioner proposed for you. We may contact the practitioner to confirm the sessions have started, and are ongoing. Be assured, your privacy is always of paramount importance to us.
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Preferences
Therapist
Coach
Either
In-person
Online
A mix of both

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*Coaches tend to have more expensive sessions, but clients see them less regularly
Me
Company
Health Insurance
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Practitioner preferences
Man
Woman
No preference
No
Yes
No preference
No
Yes
The details you enter on this document may be seen, in an anonymised form, by the practitioner proposed for you. We may contact the practitioner to confirm the sessions have started, and are ongoing. Be assured, your privacy is always of paramount importance to us.
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When would you like to see your practitioner?
Pre-Work
9am-11am
12pm-2pm
3pm-5pm
Evening
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
The details you enter on this document may be seen, in an anonymised form, by the practitioner proposed for you. We may contact the practitioner to confirm the sessions have started, and are ongoing. Be assured, your privacy is always of paramount importance to us.
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Next step
Medical details
No
Yes
No
Yes
No
Yes
The details you enter on this document may be seen, in an anonymised form, by the practitioner proposed for you. We may contact the practitioner to confirm the sessions have started, and are ongoing. Be assured, your privacy is always of paramount importance to us.
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Submit details & pay
To submit your details to our experts, please complete the payment


Use the PayPal payment option to complete your order.

Once your payment has been received, it will be matched with your form and one of our team will contact you.

£66.00
The details you enter on this document may be seen, in an anonymised form, by the practitioner proposed for you. We may contact the practitioner to confirm the sessions have started, and are ongoing. Be assured, your privacy is always of paramount importance to us.
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