Please answer the following questions so that we can assess our suitability to support you right now, as well as align you with the most appropriate therapist.

Have you had EMDR Therapy before? *

Have you had any psychological therapy before? *

Have you been given an official diagnosis? *

What is your official diagnosis? *

Have you had any other health professionals help you to manage your Mental Health/Diagnosis? (Such as a GP/Doctor and any past or present Psychiatrist) *

Which professional have your consulted you mental health with? *

Do you have a Mental Health Care Plan (MHCP) from your GP? *

If you have it, please upload photos/scans of your Mental Health Care Plan (MHCP). Otherwise skip this step to go to next question.

Upload here

Date of Referral

How did you hear about Mindfully Well? *

How old are you *

One of your parent's details

Just a few more steps and we'll have everything set up for you. We need one of your parent's details so that we can contact them to consent to the appointment.

Parent - First name *

Parent - Last name *

Parent - Mobile *

Parent - Email *

Your contact details

Just a few more steps and we'll have everything set up for you. We need your contact details so that we can schedule your appointment.

Your first name *

Your last name *

Your mobile number *

Your email address *

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