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Psychology Clinic Self Referral Form

Questions marked with a * are required
Thank you for your interest in seeking help from our clinic. Please enter your information below and we will be in touch. Please make sure you click all the way through to the end to complete the whole form. Note our current availability for taking on new young people for support - if the therapist who can offer support with the difficulty you need is not available, we will not be able to offer support at this time.   
 
Dr Manuela Barona-Soyer - No current availability
BABCP-accredited Cognitive Behavioural Therapist  
Manuela specialises in treating anxiety, depression, and issues related to perfectionism in young people (aged 16-25). She uses a range of cognitive behavioural approaches including CBT and compassion-focussed work.   
 
Dr Jasmin Langdon-Daly  - No current availability
HCPC-registered Clinical Psychologist and BABCP-accredited CBT therapist.  
Jasmin offers psychological assessment and therapies for eating disorders and eating difficulties, anxiety, and difficulties with high self-criticism.   
Professor Ailsa Russell  - No current availability 
HCPC-Registered Clinical Psychologist and BABCP-accredited CBT therapist. 
Ailsa provides cognitive behavioural therapy for autistic young people and adults (aged 16+) who are experiencing mood and anxiety difficulties.  
 
Erica Pavord - No current availability
UKCP Registered Systemic Psychotherapist
Erica works with individuals, couples and families to explore their relationships and the difficulties that can arise between people. Systemic Therapy can help develop insight and understanding,  improve communication and build stronger relationships. 

Dr Aikaterini (Katrina) Tavoulari - Space available
Chartered Disability Practitioner with the National Association of Disability Practitioners
Katrina offers specialist support to students with sight loss, vision impairment, or blindness, particularly in relation to depression, mental wellbeing, and accessibility-related challenges.

Trainee clinical psychologist - Space available starting soon
We also have a trainee clinical psychologist starting a training placement within our service. He will be offering support for low mood, anxiety, difficulties with perfectionism, self criticism, or some eating difficulties. If you would be happy to be supported by the trainee clinical psychologist, please mention this in your online referral form. 
First name
Last name/ Surname
Bath University Email
Preferred email (if different)
Phone
Date of Birth
Which clinician(s) are you interested in working with? List name(s)
Please summarise the problems you are seeking help for (one or two sentences)
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