Child & Adolescent Enquiry

Your Name

Phone Number

I confirm I am the client or the client's parent or legal guardian.

Your Email

Confirm Email

Please note we are not able to accept enquiries from third parties (aunts, grandparents, siblings, etc.)

Is it ok to leave a voicemail? YesNo

Preferred form of contact EmailPhone

Please let us know what brings you to seek support at this time. This information is confidential and is reviewed by a senior therapist. It helps us place you with a suitable therapist..

Have you had therapy before? YesNo

Age of child

4567891011121314151617

Days & Times You Are Able To Attend Appointments:
Weekday daytimesWeekday eveningsWeekends

Do you have any special requirements to physically access the building? YesNo

Do you prefer a male or female therapist? MaleFemale

If your preferred gender is not available, would you be willing to consider the alternative gender?
YesNo

Preferred therapist(s)

How did you hear about Mind Garden?

I am happy to be contacted by Mind Garden for feedback on the service provided. YesNo

In accordance with the GDPR, please indicate consent below:
Yes I understand that my email address will be used for communication regarding the above appointment request. I understand that in order for my appointment request to be processed, the above information will be passed to a suitable therapist(s) who will contact me directly.Yes I understand that my information will be kept on file for the statutory period as determined by the British Association for Counselling & Psychotherapy/United Kingdom Council for Psychotherapy/British Psychological Society or equivalent.

Please note that if you are in crisis you should contact the West Berkshire Crisis Response Team on 0300 365 2000. Alternatively go to your nearest Accident & Emergency or call 999.