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First Name*

Last Name*

Username*

Email*

Email repeat*

Password (minimum 8 characters)*

Password Repeat*

Phone Number your therapist can reach you at?*

Phone Country

Timezone*

Date & Time Available

Please select a time for your complimentary (free) 15 minute call with your intake consultant.

Select a date & time (Europe/London timezone)

This information is optional, but the more you can answer the better we will be able to prepare for the call.

Concerns

We are a Global Service and see client's through video conferencing. Are you ok with seeing your mental health provider through video conferencing? Yes No

Are you looking for: Individual
Couples
Family
Group Sessions
Workshops

Do you require morning, afternoon, evening or weekend session times Any Time
Morning
Afternoon
Evening
Weekends

Describe your situation which you are struggling with

Do you have a mental health diagnosis? Mood Disorder
Addictions
Eating Disorder
Personality Disorder
Complex PTSD
Anxiety Disorder
ASD
ADHD
Other

Are you currently in any legal proceeding? Yes
No

Are you seeking court ordered therapy? Yes
No

Is your goal for sessions to be focused on healthy coping strategies only, client led sessions, or a combination of both Healthy coping strategies only
Client led sessions
A combination of both

I find it helpful to be supported by other's with similar problems? Yes
No

I struggle to speak open and freely about how I feel Yes
No

Do you have a specific therapeutic intervention you are looking to receive? If so, please mention it here.

Customer Service — "Thank you for submitting your information. We will contact you at the date and time you selected (we'll email you an appointment confirmation to remind you)."

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