Therapy Enquiry Form "*" indicates required fields Name* First Last Date of Birth:* Day Month Year Gender:* Preferred Pronoun:He / HimShe / HerThey / ThemPrefer not to sayYour Religion:AgnosticAtheistBuddhistChristian/C of E/R. CatholicHinduJewishMuslimSpiritualistOtherEthnic Origin:White English/Welsh/Scottish/Northern Irish/BritishWhite IrishWhite - Other backgroundWhite and Black CaribbeanWhite and Black AfricanWhite and AsianOther Mixed/Multiple ethnic backgroundIndianPakistaniBangladeshiChineseOther Asian backgroundAfricanCaribbeanOther Black/African/Caribbean backgroundArabOther ethnic groupWhat days & times could you attend therapy?* Monday Mornings Monday Afternoons Monday Evenings Tuesday Mornings Tuesday Afternoons Tuesday Evenings Wednesday Mornings Wednesday Afternoons Wednesday Evenings Thursday Mornings Thursday Afternoons Thursday Evenings Friday Mornings Friday Afternoons Friday Evenings Are you looking for therapy to be in-person or online?* In-person Online Either Email address:* Enter Email Confirm Email Contact Phone Number:*Best time for Josh to contact you:*NOTE: This applies for the initial telephone consultation. Mornings Afternoons Evenings Select AllPlease select options that best describe your current main concerns or difficulties: Addictions ADHD/ASD Anger Issues Anxiety Bereavement Bullying Childhood Communication Difficulties Death & Dying Depression Domestic Violence Drugs & Alcohol Eating Disorders Extreme Highs & Lows Family Conflict Health Anxiety LGBTQ+ Minority Stress OCD Overwhelmed Panic Attacks Personality Disorder Post-Natal Depression Phobias Problems Around Intimacy PTSD Questioning Life's Meaning Relationships Self-Esteem Self-Harm Separation Sexual Abuse Social Anxiety Stress Suicidal Trauma Other Would you like help with your physical health too? Yes No How did you hear about Body Mind with Josh?*BACP WebsiteCounselling DirectoryGoogleRecommendedSocial MediaWord of MouthOtherIf other, please specify?* CommentsThis field is for validation purposes and should be left unchanged.