Registration Form - My Therapist Online

First Name (person wanting therapy)

Last Name

I am looking for

Individual Therapy Couples / Relationship Therapy Group / Family Therapy

Age

As you are under 18, we require contact details of the trusted adult supporting you with your application.

Age of minor

Trusted adult full name

Trusted adult email

Please indicate your relationship with your trusted adult

Please expand on the particular problems you would like help with

How often do these challenges affect you?

Constantly (almost all the time) Daily (at least once a day) Frequently (A few times a week) Other

Can you identify any triggers or events that seem to be linked to these challenges?

Have you tried any self-help or coping strategies that have been particularly effective or ineffective for you?

Yes No

Are you looking for a specific therapeutic approach (e.g. CBT)?

Yes Not sure No

Have you ever been diagnosed with a mental health condition?

Yes Prefer not to say No

Are you currently taking any medications or receiving any other forms of treatment?

Yes No

Do you have any specific goals or outcomes you hope to achieve through therapy?

Yes No

Is there anything else about your background, history, or current circumstances that you believe is important for a potential therapist to know?

Have you ever considered ending your life?

No, never I have thought about it, but I would never act on it Within the past 3 months I have made plans to or attempted to end my life I am planning to end my life

By selecting this option, please continue

To better understand your level of risk, please provide us with some information about your recent plan or attempt?

More recently, have you been experiencing suicidal thoughts? If so, have you contemplated specific methods or had any intentions of acting upon these thoughts?

Have you taken any steps, started preparations, or made any plans to end your life?

What safety measures or plans do you currently have in place to keep yourself safe?

Do you have any specific preferences for your therapist (e.g gender)?

Yes No preferences

What our Therapist's charge (on average):

Psychologists are trained in mental health assessment and diagnosis, and they provide therapy for a wide range of psychological issues. They often hold a doctoral degree and use evidence-based techniques to help you understand and change thought patterns and behaviours.

CBT (Cognitive Behavioural Therapy) Therapists specialise in a structured, time-limited therapy that focuses on identifying and changing negative thought patterns and behaviours. This approach is effective for anxiety, depression and a wide range of mental health problems.

Counsellors offer a safe and supportive space to talk about your feelings and issues. They help you explore and understand your problems, providing guidance and coping strategies, often focusing on personal development and wellbeing.

I understand and can afford these sessions

I am looking for & can afford sessions with a

My sessions will be paid for by

My preferred session timings: (Select all that apply)

I would like to request a specific therapist

Yes No

My preferred therapist is:

Email address

Mobile Number

Timezone (if not UK)

Send me my therapist recommendations by

Email only Email & text message / WhatsApp (often more efficient)

My Therapist Online Terms & Conditions & Privacy Policy

I have read and agree with the Terms & Conditions and Privacy Policy