The Sign-Up Form

for GPs, Health, Education, Council and Social Care Professionals.

Please fill in our Sign-up form in order to refer a client of yours to us for diagnosis and/or treatment. Submitting the form means you have agreed to our Terms & Conditions, and once your information is approved you and your client will receive an email confirmation and can book and use any of our online services thereafter.

Fields with an * are required to be filled-in.

Name of Referrer

First Name

Last Name

Profession of Referrer

Organisation of Referrer

Name of Client

Who is the client who you would like to refer?

First Name

Last Name

Date of Birth of Client

MM

DD

YYYY

Gender of Client

We request this information as gender may be hormonally relevant if medication is prescribed, or for group allocation.

Male

Female

Non-Binary

Other

Please state client's preferred gender if they so wish:

Address of Client

Address 1

Address 2

City

State/Province

Zip/Postal Code

Country

NHS Number (if available)

Client Email

Reason for Referral

Risk Assessment Summary

Please summarise any Risk Assessments you have conducted regarding your client. (I.e. Also whether they are/may be a hazard to themselves or others.)

Urgency of Assessment Required

How urgent does your client need to be contacted for treatment?