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    Your name (required)

    Your email address (required)

    NB. Make sure this is correct as I will write back to you via email.

    Your age (required)

    NB. This is to confirm that you are an adult.

    Your enquiry (required)

    Name of your referer and his/her organisation (if any)

    Are you seeing a doctor? (required)
    NoYes, I am seeing a psychiatrist.Yes, but not a psychiatrist.

    • We intend to respond to your enquiry within a few days. If for any reason you don’t hear from us, please contact us via e-mail with all relevant information.
    • We will need a referral letter from your doctor at your first appointment.