Request for mental health support

Please complete the form below to request support. When we receive your information, a member from our team will be in touch to arrange a session.

How it works

Step 1

Request therapy and submit details to Living Well.

Step 2

Request is reviewed by our team and pre-therapy interview arranged.

Step 3

Appropriate therapist is contacted and an appointment is arranged.

Step 4

Appointment is confirmed and therapy takes place.

What is a pre-therapy interview? It is a 15 minute call with a member of our team to find out more about your mental health support needs. This allows us to match you with the appropriate therapist.

Read more about the pre-therapy interview.

Appointment request

First name*

Last name*

Date of birth*

Gender*

Ethnicity*

Disability*

Registered GP*

Your NHS number

If you don't know your NHS number, you can use the Find your NHS number service to find it.

We ask for the above personal information to help us find appropriate therapists.

Mobile number*

Home address*

Postcode*

We require your contact information so that we can get in touch to book your therapy appointment.

Preferred contact method (Select all that apply)

Phone call

Text message

What time would be best to contact you? (Select all that apply)

Morning between 9:00 AM and 12:00 PM (weekdays)

Afternoon between 1:00 PM and 5:00 PM (weekdays)

Preferred method of therapy

Phone call

Video call

In person

I accept the privacy policy*