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What is your relationship?*
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What is their age?*
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Where are they currently located?*
City/Town*
Country*
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What service is required?*
Assessment
Therapy
I don't know
Question 5/9
What session format do they prefer?*
In-person
Online
Phone
No preference
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Briefly describe your concerns and share any preferences for their ideal professional (e.g., specialization, gender, availability)*
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What is the preferred method of payment?*
Self-funded
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Who is the health insurance provider?*
AXA
BUPA
AVIVA
CIGNA
VITALITY
WPA
What is the budget?*
Limited < £100
Mid-range £120 - £150
Unlimited > £150
Question 8/9
How did you hear about My Triage Network?*
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Name*
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