Home > Mental health screening 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? YourselfYour child Your child's details Child's date of birth Next Your details Your contact details Date of birth Please indicate preferred contact method PhoneEmail BackNextHow can we help? Please select yes/no for all options Anxiety YesNo Low Mood YesNo Self Esteem difficulties YesNo Sleep Difficulties YesNo Burnout YesNo Big life changes YesNo Book an appointment Other YesNo Please provide as much detail as you are willing to share. BackNextAre you currently under the care of any other Mental Health Services?YesNo 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 YesNo 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.YesNo 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. BackΔ Psychological Therapy for Children and Adults Our team of therapists can help with Fee Guide Meet the Team FAQs Book appointment
