Referral Form – restorecmc

Title

First Name *

Last Name *

Middle Name (optional)

Email Address *

Phone Number

Country of Permanent Residence

What would you like to look at in therapy?

Counsellor Required? *MaleFemale(Please note: We will endeavour to accommodate preferences but cannot guarantee session availability.)

Please select your preferred counselling time slots:

Day

MorningAfternoonEvening

Saturdays we will be available till 1pm only.

Counselling Fees

Fee Scale are dependent on your income: 
Our counselling sessions will range from £25 to £40 
For individuals with a low income, the sessions will be charged at £25 
For individuals with a high income, the sessions will be charged at £40.

Note

All fees are payable directly to your individual counsellor.
If you need to cancel or reschedule an appointment, we ask you to give 48 hours’ notice.
If sessions are missed or cancelled less than 48 hours before the schedule session, the full session fee will be applicable, as your session slot cannot be reallocated.

Individual Counselling