LACAP online submition form
LACAP online submition form

Thank you for contacting us.
Please allow us 1 to 2 business days to respond to your inquiry.

This form is sent via our secure server and your information will not be used for any purpose other than this consultation.


 
Your name:    
Your email address:    
Your mobile number:    
Your home number:     (optional)
Your work number:     (optional)
Your date of birth:    
Your Address:     House No: . 
      Street Name:
      Post Code:  
Would you like us to call you?    YES NO
Would you like us to email you?    YES NO
 
Do you have a preference?

 

 

      Female Therapist      

  

    Male Therapist         
    No preference          
 
OR: 
       
 

For an 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: Earliest Start  Latest Start
Monday  YES NO
Tuesday  YES NO
Wednesday  YES NO  
Thursday            YES NO
Friday                YES NO 
Saturday            YES NO 
Sunday               YES NO
More information about the times that I can make: -
 
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 now, but without your income declaration, the initial consultation fee will be £40.00.
 
   
    I can declare my income at this stage    YES NO
 
    My Annual gross income is:     
   
 
Please let us know anything that might be of particular relevance at this stage.

The main premises are not particularly suited to impaired mobility. If you can let us know if you have a difficulty in mobility we can arrange your consultations/meetings at a location commensurate with your needs.

Thank you for filling this out. Please send it to us using the 'send' button below.

 
 
LACAP
10 Cobb Street, London E1 7LB
19 Wentworth Street  London E1 7TB
telephone number given on email request
Private policy