Email Application Form for Counselling & Psychotherapy in London

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Please only use this form if you are applying at standard fees! If you want help with fees use the Online Application form.
first name:
last name:
email address:
mobile number:
home number:		* Not Required
work number:		* Not Required
date of birth:
address:	house no
	street name
	post code
Call ok?	Yes No
Email ok?	Yes No

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For the initial consultation, please indicate days and times that are usually possible for you to make on an ongoing basis. We will try to meet those
times requested, but for the first meeting might ask you to be a little more flexible about attending. Lacap will arrange an initial consultation based on the information you have supplied, so please do be careful to enter the correct information for us.

My available days are:		First	Last
Monday	Yes No
Tuesday	Yes No
Wednesday	Yes No
Thursday	Yes No
Friday	Yes No
Saturday	Yes No
Sunday	Yes No

Tell us more about your possible times!

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Please tell us your preferences & circumstances

I would prefer to see:

Only a male therapist
Only a female therapist
I have no preference

I am telling you my income

Yes No

My annual gross income is

NOTE ! You are applying at standard fee rates. If you let us have a note of your annual gross income, we can let you have a note of the cost of the initial consultation & ongoing meetings.

You do not have to tell us about your income, but without your income declaration, the initial consultation fee will be £50.00.

Please let us know in this box anything that might be of particular relevance at this stage.

Thank you for your application.
Please post it to us using the 'send' button below.