Referral form

If you would like to:

  • request a referral for psychotherapy
  • or apply for the low fee scheme

please contact us at or complete the form below.

Based on your individual situation (e.g. your locality, type of therapy preferred) you will be offered two or three names of therapists you can contact. Please complete the form as far as you can to help us to make an appropriate match for you.

This form can also help with selecting a supervisor.

Your name:




Male        Female 

Telephone (day):

Telephone (evening):



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

Please write briefly why you are seeking therapy:

Have you ever used mental health services (NHS or private)?

Yes            No

If yes please give details:

Have you ever been prescribed medication for your mental health or used mental health services (NHS or private)?      

Yes            No

If yes please give details:







The West Midlands’ leading professional and training organisation for psychoanalytical and Jungian analytical psychotherapies.