MindKind - Directory Application Form

First name

Last name

Your Personal Address

Personal Address Postcode

Email

Phone

Your Gender

Your preferred Pronoun

Nationality & Ethnicity

Do you speak any other language(s)?

Private Practice Address

Private Practice Postcode

Qualification

Registered Counsellor

Accredited Counsellor /Psychotherapist

Psychologist

Professional Membership Upload

Qualification Certificates

Proof of Professional Insurance

Your professional headshot photo

Mode of therapy offered ?

In-person

Online

Telephone

Your Supervisor's name, Prof. registered number and contact telephone number

Please detail your fees charged and whether they differ for in-person or online; and the working hours you are available during the week.

Please provide a Professional Biography

Declaration: By submitting this application, I confirm that the information provided is accurate and complete to the best of my knowledge. I agree to abide by MindKind's Terms and Conditions, Privacy Policy and Private Therapist Contract, including the agreed fee structure whereby any first session booked by a client will be charged as MindKind's referral fee; and thereafter the referred client becomes my sole clinical responsibility.

Signature

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MindKind is not an in-crisis service. Please contact your GP, call NHS 111, or in the event of emergency, go directly to A&E.

THERAPY SERVICES

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For student therapists looking for a placement, then discover more here.

MindKind - Directory Application Form

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