Havering Drug and Alcohol Action Team
My Chosen Treatment/Support Type is:
To see different Treatment/Support Types and the Fees, visit the link below:
My Other Preferences (Put X on your preferences):Select as many preferences as possible to help us increase the chances of quickly allocating you to a therapist/counsellor. We shall try to accommodate your preferences but no guarantee and no obligation on Health City to meet your preferences. If we can’t accommodate your preferences and you decide not to receive available alternatives to your preferences, we shall offer you a full refund of your fee paid.
Days: Monday ( ), Tuesday ( ), Wednesday ( ), Thursday ( ), Friday ( ), Saturday ( ).
Time Period: (UK time stated here, so clients based outside the UK must adjust for time difference between the UK and their country): Morning from 6am ( ), Noon from 12pm ( ), Evening from 4pm ( ), Evening from 6pm ( ), Evening from 9pm ( ).
How You Like to Receive Support:
- Face to Face (you coming to Health City’s professional): Canary Wharf ( ), London Bridge ( ), other parts of London not too distant from Canary Wharf and London Bridge ( ).
- Face to Face (additional fee applies if Health City professional going to your home, office or other agreed venue to suit you): Canary Wharf ( ), London Bridge ( ), Other parts of London not too distant from Canary Wharf and London Bridge ( ), Outside London ( ), Overseas ( ).
- Online ( ), Email ( ), Phone ( ), Text messaging ( ), postal letter or fax ( ).
- I don’t mind my full identity known to the professional ( )
- I want my identity protected from the professional but not from Health City ( )
- I want sessions in (a) English language ( ), (b) other languages ( )
- I want a therapist who is aware of a specific: (a) faith (e.g. ), (b) culture (e.g. ).
- I want a therapist of a specific gender (e.g. ).
Fee Payment Preference (Chose only one Option below).
I am Self-Funding/Paying the Fee Myself on submission of this Form. I will not receive an
appointment until my booking is paid with cleared funds.
Your Chosen Fee: £ Your Chosen Method of Payment:
I am being Funded by an Organisation/Someone (including Insurance Firm, Commissioners’ or
other Corporate Body. My Pre-Authorisation number is: Number of sessions:
Phone and address of my funder to verify funding:
- I will not receive an appointment until Health City verifies my authorisation with my funder.
- If you are funded by an organisation, we will offer you an appointment and invoice them later.
- If you are funded by an individual, you will not receive an appointment until they paid your
Your information
Title/Surname: / First name:
Previous names: / Preferred name:
Date of Birth/Age: / Ethnicity: / Gender: / Phone:
Email: / Address/Postcode:
If you are affiliated/associated with any organisation (Optional): Organisation’s name: Address/Postcode: Phone: Email:
Do you have a GP, Family or Private Medical Doctor? Yes/No
Do you want us to share details of your therapy with your Doctor? (Yes/No). OR do you want your Doctor to receive only a letter confirming your referral and attendance? (Yes/No) *Additional fee applies when you request a report to be sent to your doctor or another organisation.
Doctor’s name (if known): Organisation’s name/Address:
Phone: Email (If any):
Summary of the difficulty/problem you want support from Health City (DON’T GIVE FULL HISTORY HERE FOR YOUR PROFESSIONAL SHALL COMPLETE AN ASSESSMENT):
Any child who may be affected by the difficulties that help is being sort? / Yes/No
If Yes, give brief summary ONLY (not much details, goal is to support you and any child affected):
Summary of illicit drugs, alcohol use and prescribed and non-prescribed medications (if any) for mental health:
Risks and concerns you want us to be aware of:
Faith, cultural or personal beliefs you want us to take into account while working with you:
Physical/medical health conditions and prescribed and non-prescribed medications:
- Information given on this form is correct to the best of my knowledge.
- I have agreed to the information on this form, including the terms below that accompany this Health City’s Therapy Booking Form.
When completed, please submit Online or email or post this form to:
Health City, Davenport House,16 Pepper Street, Canary Wharf, London E14 9RP.
Tel: 03338003006, .
Health City is trading name for Enaikidigha Trade & Investment Ltd (reg. 6222197).
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TERMS AND CONDITIONS
By booking I accept the following:
1.0Health City’s Payments: We offer a number of ways to help you pay for your services:
1.1 Bank transfer is our preferred payment method:
Bank HSBC, Sort Code: 40 07 04, Account number:71828835. Account name: Enaikidigha Trade & Investments Ltd (trading as Health City).
Payment reference: Your initials, surname and date you received the service e.g. J.Kane23/06/16.
1.2Alternative payment methods:
(a)Therapy and Counselling can be paid via all health insurance firms including: Standard Life, Cigna, AVIVA, AXA PPP,BUPA International, PruHealth.Note:BUPA UK is only accepted by some of our therapists. AXA PPP clients need a psychiatric referral first.
(b)Direct Debit:Clients can set up a direct debit payment usingtheir bank.
(c)Debit/Credit Card:Clients can pay viaPayPalor‘Go Cordless’. They will charge you a small fee.
1.3Payments for Counselling, therapy and treatment servicesare in advance. This can be via any of the payment options offered by Health City. A receipt will be emailed to you.
1.4Travel Fees: Home, office and school visits requiring our therapist to use a public or private transport will incur extra fee to reflect the therapist’s expenses and time away from the clinic.
2.0Cancellation policy:Evidence is that regular attendance helps with recovery, so to motivate attendance, full fee will be paid for missed or cancelled sessions even with advance notice. Also another client would have benefited from the missed or cancelled session.
3.0Waiting rooms: Please note that there are no evenings’ and weekends’ reception staff in the waiting rooms in some of our offices or clinics, so clients will be asked to meet their professionals at the exact appointment time.
4.0 Referral
4.1 I agreed to my referral to Health City and I shall becontacted for appointment, assessment and service provision.
4.2 I agreed that even if I refused information to be shared with my GP, Family or Private Medical
Doctor (Health City respects your decision and privacy) it is my Doctor (and not Health City) who holds the medical responsibility for my medications and healthcare.
5.0Sharing information:I agreed for my information to be confidentially used within Health City for the purposes of providing me a better care and Health City’s supervision and training.
6.0RISK OF HARM AND EMERGENCY SUPPORT:
6.1I agreed that Health City is not an emergency service, so its email, telephone, personnel and service are not to be used in an emergency.
6.2If I am in distress and worried about immediate risk of harm to myself or others, I will go to or contact my nearest Accident Emergency service.
6.3If I am not at immediate risk but in distress and like to have support and advice, I will contact my GP, Family or Private Medical Doctor.
- People in the UK can contact: Alcoholics Anonymous – 0845 769 7555. Website:
- Useful Websites
- Free self-help workbooks for emotional or mental health problems.
Free online life skills course working.
Health City helping families attain psychological, physical, financial and legal wellbeing to stay happily and safely.
Web:
Tel: 0333 800 3006
Opening hours: Monday-Friday 8am-11pm; Saturday 8am-9pm. Non-face to face services are offered 24 hours.
Address: Health City, Davenport House, 16 Pepper Street, Canary
Wharf, London E14 9RP, United Kingdom.
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