Book a Therapy Session

    Enquiry form

    The information you submit is safe. Data you send via this form is encrypted and is stored securely on MyHealthcare Clinic servers. If you are filling this out as a referral for your child, please include their details also.

    Who are you completing this form for?

    Your child's details

    Child's date of birth

    Your details

    Your contact details

    Date of birth

    Please indicate preferred contact method

    How can we help? Please select yes/no for all options


    Low Mood

    Self Esteem difficulties

    Sleep Difficulties


    Big life changes


    Please provide as much detail as you are willing to share.

    Are you currently under the care of any other Mental Health Services?

    Do you currently feel at risk (e.g. of self-harming, or even thoughts of not wanting to live)? If so, please access these resources

    We would like to remind you that this is a virtual therapy clinic. If there are any concerns about this, please see the Frequently Asked Question (FAQs) surrounding virtual therapy.

    We also will be running virtual workshops covering a range of topics such as sleep, stress management and burnout. Please let us know if this is something you would like more information on by agreeing to be added to our mailing list.

    Thank you for completing this form. Dr Michalczuk will be in touch shortly. By submitting this form, you agree with the storage and handling of your data by our team.

    If you are in a life-threatening situation, don't use this enquiry form. Use these resources to get immediate help.