Psychotherapy Consultation - Application Form

The Fairbridge Clinic low fee scheme is temporary on hold for accepting new patients for the next few months.

This form is for booking a consultation (also known as an assessment) with an AGIP assessor.The AGIP assessor can then recommend your next step and, if suitable, refer you to a psychotherapist that will suit you.

There are three price levels for the consultation. Please select the most suitable one.

Payment will be via PayPal. Note that you do not need a PayPal account, you can still pay by credit or debit card. If you do not want to use PayPal or are not sure which price level applies to you, please phone the AGIP Office on 020 7272 7013 and say you wish to book an assessment.

We will send you a short questionnaire which will need to be completed before the consultation appointment.

Select Service:

Select Service:Full Fee Assessment (£70)Concessionary Assessment (£50)Fairbridge Clinic Assessment (£35)

Your Name:*

First

Last

Your E-mail:*

Your Address:

Street AddressStreet Address Line 2CityPostcode

Your phone number:*

Preferred Contact Method:*

Email

Phone

Post

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