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West Midlands Institute of Psychotherapy
36 Harborne Road, Edgbaston Birmingham B15 3AF Tel/fax 0121 455 7888
email: admin@wmip.org

 

 

Referral service

If you would like to request a referral for psychotherapy or are seeking a supervisor of psychological work please contact us at
referrals@wmip.org or complete the form below.

An alternative route to identifying an appropriate psychotherapist for you is by completing a Referral Request Form and posting it to:

Referral & Supervision Service
WMIP
36 Harborne Road
Edgbaston
Birmingham B15 3AF

Based on your individual situation (e.g. your locality, type of therapy preferred) you will be offered two or three names of therapists whom you can contact.

This form allows therapists to have a brief knowledge of the applicant and you are asked to complete it as far as you can. It will help us to make an appropriate match for you.

Download the referral request form (pdf)

On-line Referral Request Form

Your name:

Title:

Age:

Address (home):

 

Town:

County:

Post Code:

Telephone (day):

Telephone (evening):

Email:

 

If you prefer not to be contacted at home, please provide alternative contact details:
 

Address 2

 

Town:

County:

Post Code:

Telephone (day):

Telephone (evening):

Email:

 

Please indicate your preferred area(s) for the location of a psychotherapist.

Please write briefly why you are seeking therapy:

 

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West Midlands Institute of Psychotherapy
Company Limited by Guarantee (No 2883306)
Registered Charity (No 10310110)
Member of UK Council for Psychotherapy

Web site by Sandra Dillon sandra@realcom.co.uk
Fractal art images by Susan Graves at www.shimmerfire.co.uk