First Name

Last Name

Email Address

Phone Number

Your availability for appointments (Please select as many options as possible)

Monday 9am - 1pmTuesday 9am - 1pmWednesday 9am - 1pmThursday 9am - 1pmFriday 9am - 1pmMonday 1pm - 5pmTuesday 1pm - 5pmWednesday 1pm - 5pmThursday 1pm - 5pmFriday 1pm - 5pmMonday 5pm - 9pmTuesday 5pm - 9pmWednesday 5pm - 9pmThursday 5pm - 9pmFriday 5pm - 9pm

Therapy Mode Preference
---Face-to-FaceTelephoneOnline Video (e.g: Skype, Zoom)

Therapist gender preference
---MaleFemaleNo preference

Does your medical insurance (VHI, LAYA, Irish Life) cover psychotherapy or counselling sessions?

YesNo
Please note medical insurance cover for therapy and counselling is based on individual registered therapist / counsellor names and not ‘LifeChange’ as a practice - please consult directly with your insurance provider for more details specific to your policy.

Your Message

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