icap referral form

icap clinical team


Please fill out the form below

This form is to help us assess your needs.

Please answer the following questions as fully as you are able to.

All the information you give us will remain confidential to icap.

DOB format should be similar to 20/10/1973
Camden, Islington, etc
If you were born in Ireland, please state what county:
(if you weren't born in Ireland, please indicate where?)
(if applicable)
If yes, please can you tell us when and what treatment was recommended?
Please provide more details above
Only share information on this form if this feels appropriate.
Indicate above or tick the appropriate boxes below

What people say?

It has allowed me to access a service that I would not otherwise be able to afford. The service provided has helped me immensely by the therapist listening in a non-judgmental manner, giving me skills and techniques to apply to my daily life to help me get out of a bad headspace
icap client