Intake Form


Please fill the form below before our first session. You can express yourself as much as you need.

What you write in this form remains strictly confidential. As a therapist this is my code of ethics (as regulated by the GHSC council).
By filling it, you help me to help you better and you help yourself to brainstorm on why you want to change.

To contact you in case I need.
For example, if your goal is to quit smoking, some benefits might be: "I want to feel healthier." or "I want to safe money.
For example, if your goal is to quit smoking, some benefits might be: "I want to feel healthier." or "I want to safe money".
Signature (type your name)

FEE
First 1.5hr session £130
Subsequent 1hr session £110 each

PAYMENT
Each session fee is payable by bank transfer prior to each session, or cash on the day.

Bank: HSBC
Account holder: Laura Artero
Account number: 81501909
Sort code: 40-07-06

Thank you.