Enquiry form Leicester : The Cooley Practice

Are you...*

the client (i.e., the person who will be receiving the service)

acting on the client's behalf (e.g., a parent, spouse, family member, colleague, friend)

Who should we contact in response to this enquiry?

myself

the client directly

Enter your email address? * Enter the client's email address? *

Enter your telephone number? Enter the client's telephone number?

Client details

Do you Does the client have any current medical diagnoses (physical or psychological)? *

Yes

If yes, please specify:

Emotional wellness (talking therapy)

Diet

Assessment for autism

Assessment for ADHD

Coping with chronic conditions group

Holistic Health Programme

Wellbeing at work (for corporate clients)

Other groups, training, or workshops

If other, please state:

Self-funded

Insurance (Please specify your insurance provider:)

Telephone

Online video call

In-person

A combination

I'm not sure

Do you the client have any accessibility requirements? *

The focus of your the client's support

Please summarise the reason for your enquiry (e.g., what difficulties have you the client been experiencing?) *

Please summarise what you would like us to support you the client with (e.g., What are your the client's outcome goals?) *

Are you Is the client currently receiving any other professional support for your their difficulties? *

Would you consider there to be any risk associated with your enquiry (e.g., self-harm, suicidality) *

Are there any other comments you would like to add?

Please tell us how you heard about The Cooley Practice? *

Would you like to receive information about our service updates, news and/or promotional emails from The Cooley Practice?

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